Provider Demographics
NPI:1124607817
Name:IBRAHIM, AMIR
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:
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 1:20066 LAKE CHABOT RD APT 8
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546
Mailing Address - Country:US
Mailing Address - Phone:415-702-7005
Mailing Address - Fax:
Practice Address - Street 1:20066 LAKE CHABOT RD APT 8
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546
Practice Address - Country:US
Practice Address - Phone:415-702-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH84141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist