Provider Demographics
NPI:1588062608
Name:IBRAHIM, JANET
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:IBRAHIM
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 1:824 WATERTON AVE
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5125
Mailing Address - Country:US
Mailing Address - Phone:843-742-5243
Mailing Address - Fax:
Practice Address - Street 1:5405 DICK POND RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6836
Practice Address - Country:US
Practice Address - Phone:843-742-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-06
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist