MEDICARE: MATOKE INCORPORATED SOUTHSIDE PHARMACY

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	3336C0003X	Community/Retail Pharmacy	25349	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4543648	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1700943073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATOKE INCORPORATED SOUTHSIDE PHARMACY

Provider Business Mailing Address
First Line	:	14041 NORTHWEST BLVD
Second Line	:	STE 2B
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78410-5137
Country	:	US
Telephone Number	:	361-767-1300
Fax Number	:	361-767-8888

Provider Business Practice Location Address
First Line	:	14041 NORTHWEST BLVD
Second Line	:	STE 2B
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78410-5137
Country	:	US
Telephone Number	:	361-767-1300
Fax Number	:	361-767-8888

Authorized Official
Title or Position	:	PIC OWNER
Name	:	ERIC MATOKE
Credential	:	RPH
Telephone Number	:	972-207-0247

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	03/12/2013

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Directions to “MATOKE INCORPORATED SOUTHSIDE PHARMACY ” Practice Location

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