Healthcare Provider Details

I. General information

NPI: 1134030448
Provider Name (Legal Business Name): MOHAMED IBRAHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 W EAGLE RD
HAVERTOWN PA
19083-2234
US

IV. Provider business mailing address

42 S MERION AVE
BRYN MAWR PA
19010-2602
US

V. Phone/Fax

Practice location:
  • Phone: 610-853-1768
  • Fax:
Mailing address:
  • Phone: 610-659-6811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP460660
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: