Provider Demographics
NPI:1790067122
Name:IBRAHAM, GERALD JASON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:JASON
Last Name:IBRAHAM
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 1:4812 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1334
Mailing Address - Country:US
Mailing Address - Phone:757-460-1290
Mailing Address - Fax:757-460-1547
Practice Address - Street 1:4768 SHORE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-2713
Practice Address - Country:US
Practice Address - Phone:757-460-1290
Practice Address - Fax:757-460-1547
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205624183500000X
NC14138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202205624OtherVIRGINIA PHARMACY LICENSE NUMBER