Provider Demographics
NPI:1073828646
Name:MATHAI, VIMITHA
Entity Type:Individual
Prefix:
First Name:VIMITHA
Middle Name:
Last Name:MATHAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 LITCHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2713
Mailing Address - Country:US
Mailing Address - Phone:516-270-3447
Mailing Address - Fax:
Practice Address - Street 1:49 LITCHFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2713
Practice Address - Country:US
Practice Address - Phone:516-270-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-08
Last Update Date:2010-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist