Healthcare Provider Details

I. General information

NPI: 1659592418
Provider Name (Legal Business Name): KHADIJAT OLUWAWEMIMO IBRAHIM PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KHADIJAT LAWAL B.PHARM

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/27/2024
Certification Date: 07/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

9711 BYWARD BLVD
BOWIE MD
20721-1871
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax:
Mailing address:
  • Phone: 240-432-3772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19414
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: