Provider Demographics
NPI:1003192055
Name:MATIJASEC, TOMISLAV TOM (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TOMISLAV
Middle Name:TOM
Last Name:MATIJASEC
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9634 CASA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6217
Mailing Address - Country:US
Mailing Address - Phone:314-302-4659
Mailing Address - Fax:
Practice Address - Street 1:9634 CASA ROSA DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6217
Practice Address - Country:US
Practice Address - Phone:314-302-4659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006025297183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist