Provider Demographics
NPI:1972010817
Name:IBRAHIM, QUDUS A (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:QUDUS
Middle Name:A
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 1:3371 RESERVE DR APT 115
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5239
Mailing Address - Country:US
Mailing Address - Phone:708-574-3420
Mailing Address - Fax:
Practice Address - Street 1:1500 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:219-940-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-01
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026388A183500000X
IL051.298920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist