Provider Demographics
NPI:1275179863
Name:IBRAHIM, SAMAR A
Entity Type:Individual
Prefix:
First Name:SAMAR
Middle Name:A
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 SUNCHASE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-0527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 N ORANGE AVE GREEN COVE SPRINGS
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246
Practice Address - Country:US
Practice Address - Phone:904-297-4757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist