Provider Demographics
NPI:1144735291
Name:IBRAHIM, MARIO S (PHARMD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:S
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SUNDANCE TER
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07419-2428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1483 STATE RT 23 STE 12
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-1643
Practice Address - Country:US
Practice Address - Phone:973-838-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03915100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist