Provider Demographics
NPI:1386256410
Name:MAHROUS, IBTISAM
Entity type:Individual
Prefix:
First Name:IBTISAM
Middle Name:
Last Name:MAHROUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2236
Mailing Address - Country:US
Mailing Address - Phone:318-351-6655
Mailing Address - Fax:
Practice Address - Street 1:5349 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7505
Practice Address - Country:US
Practice Address - Phone:318-397-8152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist