Healthcare Provider Details

I. General information

NPI: 1447675574
Provider Name (Legal Business Name): MOHAMED I IBRAHIM RPH, CSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 N 4TH AVE
SIOUX FALLS SD
57104-0444
US

IV. Provider business mailing address

4901 N 4TH AVE
SIOUX FALLS SD
57104-0444
US

V. Phone/Fax

Practice location:
  • Phone: 800-835-3784
  • Fax: 800-973-7150
Mailing address:
  • Phone: 800-835-3784
  • Fax: 800-973-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number63430
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6130
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: