Provider Demographics
NPI:1023387719
Name:MATOESIAN, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MATOESIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 ROYAL CREST WAY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6993
Mailing Address - Country:US
Mailing Address - Phone:618-206-8004
Mailing Address - Fax:
Practice Address - Street 1:2001 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4618
Practice Address - Country:US
Practice Address - Phone:618-876-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-24
Last Update Date:2011-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist