Healthcare Provider Details

I. General information

NPI: 1750032892
Provider Name (Legal Business Name): AHMAD H IDRISS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 S 9TH ST UNIT D
MILWAUKEE WI
53204-3426
US

IV. Provider business mailing address

7725 S SCEPTER DR APT 24
FRANKLIN WI
53132-2260
US

V. Phone/Fax

Practice location:
  • Phone: 414-375-6112
  • Fax: 414-375-6113
Mailing address:
  • Phone: 414-614-8354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20636-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: