Provider Demographics
NPI:1790062453
Name:IBRAHIM, SAM (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8005 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1217
Mailing Address - Country:US
Mailing Address - Phone:219-836-2697
Mailing Address - Fax:
Practice Address - Street 1:8005 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1217
Practice Address - Country:US
Practice Address - Phone:219-836-2697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN262024319A183500000X
IL051294886183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist