Healthcare Provider Details

I. General information

NPI: 1972812246
Provider Name (Legal Business Name): ALICIA SHANA MATTSON R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 E JIMMIE LEEDS RD
GALLOWAY NJ
08205-4127
US

IV. Provider business mailing address

335 E JIMMIE LEEDS RD
GALLOWAY NJ
08205-4127
US

V. Phone/Fax

Practice location:
  • Phone: 609-748-2449
  • Fax: 609-748-0959
Mailing address:
  • Phone: 609-748-2449
  • Fax: 609-748-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI02596800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: