Provider Demographics
NPI:1164715694
Name:JATTA, CHARLO M (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:CHARLO
Middle Name:M
Last Name:JATTA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 STEWART ST
Mailing Address - Street 2:1191 STEWART STREET
Mailing Address - City:WELCH
Mailing Address - State:WV
Mailing Address - Zip Code:24801-2133
Mailing Address - Country:US
Mailing Address - Phone:304-436-4938
Mailing Address - Fax:304-294-7503
Practice Address - Street 1:401 MORAN AVE
Practice Address - Street 2:
Practice Address - City:MULLENS
Practice Address - State:WV
Practice Address - Zip Code:25882-1430
Practice Address - Country:US
Practice Address - Phone:304-294-0343
Practice Address - Fax:304-294-7503
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist