MEDICARE: SALLY IBRAHIM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	86557	CA

General Provider Information

NPI Number	:	1063121705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY IBRAHIM

Provider Business Mailing Address
First Line	:	827 W WESTWAY AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-2533
Country	:	US
Telephone Number	:	424-278-3485
Fax Number	:

Provider Business Practice Location Address
First Line	:	827 W WESTWAY AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-2533
Country	:	US
Telephone Number	:	424-278-3485
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2022
Last Update Date	:	11/22/2022

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Directions to “ SALLY IBRAHIM ” Practice Location

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