Healthcare Provider Details

I. General information

NPI: 1770041758
Provider Name (Legal Business Name): CHARLES ELIAS MATLI PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JUNCTION OF HWY 371 AND NAVAJO SERVICE ROUTE 9
CROWNPOINT NM
87313
US

IV. Provider business mailing address

3134 SUMMER DR
LAKESIDE AZ
85929-6726
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-6344
  • Fax: 505-786-2526
Mailing address:
  • Phone: 917-748-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP8174
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: