MEDICARE: GENNADIY MATATOV PHARM. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	048673	NY

General Provider Information

NPI Number	:	1295057552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENNADIY MATATOV PHARM. D.

Provider Business Mailing Address
First Line	:	13957 PERSHING CRES
Second Line	:	PH
City	:	BRIARWOOD
State	:	NY
Zip	:	11435-1944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	781 LYDIG AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-2144
Country	:	US
Telephone Number	:	718-822-1348
Fax Number	:	718-822-1792

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2010
Last Update Date	:	02/26/2010

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