Healthcare Provider Details

I. General information

NPI: 1467963108
Provider Name (Legal Business Name): JIBIN MATHEW R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 ROUTE 130 N STE 1408
CINNAMINSON NJ
08077-3046
US

IV. Provider business mailing address

1210 ROUTE 130 N STE 1408
CINNAMINSON NJ
08077-3046
US

V. Phone/Fax

Practice location:
  • Phone: 856-829-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03881900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: