Basic Information
| Provider Information | |||||||||
| NPI: | 1043300916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | MA | ||||||||
| MiddleName: | DAIYAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAIYAN | ||||||||
| OtherFirstName: | MOHAMMAD | ||||||||
| OtherMiddleName: | ABDUD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11508 CENTAUR WAY | ||||||||
| Address2: | |||||||||
| City: | LEHIGH ACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339713768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396458438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1951 W HICKPOCHEE AVE | ||||||||
| Address2: | |||||||||
| City: | LABELLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339354792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633026009 | ||||||||
| FaxNumber: | 8633026008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS38855 | FL | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 106506801 | 05 | FL | MEDICAID |