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General NPI Number Information
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NPI Number | 1811200215
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Entity Type | Individual
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Provider Name | MICHAEL MAMDOUH AZIZ IBRAHIM
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Gender | Male
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Dates
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Enumeration Date | 07/14/2010
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Last Update Date | 07/14/2010
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Provider Practice Location Address
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Address Line | 34420 YUCAIPA BLVD
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City | YUCAIPA
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State | CA
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Zip | 92399-2412
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Country | US
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Telephone | 909-797-1312
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Fax | 909-797-3158
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Provider Business Mailing Address
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Address Line | 1400 BARTON RD APT 2713
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City | REDLANDS
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State | CA
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Zip | 92373-5443
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Country | US
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Telephone | 909-797-1312
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Fax | 909-797-3158
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 63426
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License Number State | CA
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