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General NPI Number Information
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NPI Number | 1306212196
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Entity Type | Individual
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Provider Name | CHARLES KANJIRAKATTU MATHEW PHARM D
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Gender | Male
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Dates
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Enumeration Date | 08/15/2015
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Last Update Date | 08/15/2015
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Provider Practice Location Address
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Address Line | 7305 SE 29TH ST
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City | MIDWEST CITY
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State | OK
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Zip | 73110-6122
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Country | US
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Telephone | 405-455-4001
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Fax |
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Provider Business Mailing Address
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Address Line | 12800 TWIN PINES LN
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City | CHOCTAW
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State | OK
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Zip | 73020-7638
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Country | US
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Telephone | 405-249-7413
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 16179
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License Number State | OK
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