Provider Demographics
NPI:1083070049
Name:MATTAMAL, JOSY
Entity Type:Individual
Prefix:
First Name:JOSY
Middle Name:
Last Name:MATTAMAL
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 1:5434 KNOLL TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1235
Mailing Address - Country:US
Mailing Address - Phone:504-430-2101
Mailing Address - Fax:
Practice Address - Street 1:5434 KNOLL TERRACE DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-1235
Practice Address - Country:US
Practice Address - Phone:504-430-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36611183500000X
LA13007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist