Provider Demographics
NPI:1811604523
Name:MIKHAIL, IBRAM N
Entity type:Individual
Prefix:
First Name:IBRAM
Middle Name:N
Last Name:MIKHAIL
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 1:23 NORTH ELM ST
Mailing Address - Street 2:
Mailing Address - City:KUTZTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 N ELM ST
Practice Address - Street 2:
Practice Address - City:KUTZTOWN
Practice Address - State:PA
Practice Address - Zip Code:19530-1343
Practice Address - Country:US
Practice Address - Phone:610-683-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP457157183500000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacist