Provider Demographics
NPI:1811200215
Name:IBRAHIM, MICHAEL MAMDOUH AZIZ
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MAMDOUH AZIZ
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BARTON RD APT 2713
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5443
Mailing Address - Country:US
Mailing Address - Phone:909-797-1312
Mailing Address - Fax:909-797-3158
Practice Address - Street 1:34420 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2412
Practice Address - Country:US
Practice Address - Phone:909-797-1312
Practice Address - Fax:909-797-3158
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist