Provider Demographics
NPI:1114654084
Name:MATHEW, MINI
Entity Type:Individual
Prefix:
First Name:MINI
Middle Name:
Last Name:MATHEW
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 1:1401 GREENHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1734
Mailing Address - Country:US
Mailing Address - Phone:972-951-5973
Mailing Address - Fax:
Practice Address - Street 1:1401 GREENHAVEN DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1734
Practice Address - Country:US
Practice Address - Phone:972-951-5973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist