Provider Demographics
NPI:1043300916
Name:IBRAHIM, MA DAIYAN (RPH)
Entity type:Individual
Prefix:
First Name:MA
Middle Name:DAIYAN
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:ABDUD
Other - Last Name:DAIYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:11508 CENTAUR WAY
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-3768
Mailing Address - Country:US
Mailing Address - Phone:239-645-8438
Mailing Address - Fax:
Practice Address - Street 1:1951 W HICKPOCHEE AVE
Practice Address - Street 2:
Practice Address - City:LABELLE
Practice Address - State:FL
Practice Address - Zip Code:33935-4792
Practice Address - Country:US
Practice Address - Phone:863-302-6009
Practice Address - Fax:863-302-6008
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106506801Medicaid
0556050458Medicare ID - Type Unspecified