Provider Demographics
NPI:1841831088
Name:IBRAHIM, SAMAH MOHAMED (RPH)
Entity type:Individual
Prefix:MRS
First Name:SAMAH
Middle Name:MOHAMED
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 GROVELAND
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-2826
Mailing Address - Country:US
Mailing Address - Phone:805-720-4563
Mailing Address - Fax:
Practice Address - Street 1:105 W BASTANCHURY RD STE D
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2525
Practice Address - Country:US
Practice Address - Phone:714-500-7727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist