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General NPI Number Information
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NPI Number | 1922656321
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Entity Type | Individual
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Provider Name | ELIE MATTA PHARMD
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Gender | Male
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Dates
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Enumeration Date | 08/28/2019
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Last Update Date | 08/28/2019
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Provider Practice Location Address
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Address Line | 5851 MERCURY DR
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City | DEARBORN
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State | MI
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Zip | 48126-4161
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Country | US
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Telephone | 313-441-0194
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Fax |
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Provider Business Mailing Address
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Address Line | 5438 HARTWELL ST
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City | DEARBORN
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State | MI
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Zip | 48126-3311
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Country | US
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Telephone | 313-717-8209
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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 | 5302411941
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License Number State | MI
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