Healthcare Provider Details

I. General information

NPI: 1073993010
Provider Name (Legal Business Name): SUSAN MATHEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7941 OXFORD AVE
PHILADELPHIA PA
19111
US

IV. Provider business mailing address

7941 OXFORD AVE
PHILADELPHIA PA
19111-2224
US

V. Phone/Fax

Practice location:
  • Phone: 215-745-9060
  • Fax:
Mailing address:
  • Phone: 215-745-9060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP040442L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: