Provider Demographics
NPI:1336453117
Name:IBRAHIM, TONY
Entity Type:Individual
Prefix:
First Name:TONY
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 1:16950 JASMINE ST
Mailing Address - Street 2:APT#22
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7805
Mailing Address - Country:US
Mailing Address - Phone:760-987-6796
Mailing Address - Fax:
Practice Address - Street 1:14629 7TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4019
Practice Address - Country:US
Practice Address - Phone:760-245-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63819183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist