Healthcare Provider Details

I. General information

NPI: 1558674291
Provider Name (Legal Business Name): SHYLA J MATHEW RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHYLA JOSEPH RPH

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12202 LIBERTY AVE
SOUTH RICHMOND HILL NY
11419-2114
US

IV. Provider business mailing address

23 RIDGE CT
HAUPPAUGE NY
11788-4748
US

V. Phone/Fax

Practice location:
  • Phone: 718-843-7001
  • Fax:
Mailing address:
  • Phone: 410-814-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number054578
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17608
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: