Healthcare Provider Details

I. General information

NPI: 1548281223
Provider Name (Legal Business Name): ELBA R MATHEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE SONIA AJ-16 VILLA RICA
BAYAMON PR
00959
US

IV. Provider business mailing address

Q88 CALLE 21 BELLA VISTA GARDENS
BAYAMON PR
00957-6110
US

V. Phone/Fax

Practice location:
  • Phone: 787-785-5487
  • Fax: 787-786-9100
Mailing address:
  • Phone: 787-243-7211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number1160
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: