Provider Demographics
NPI:1194209114
Name:MATTA, MARIAM
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:MATTA
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 1:200 WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4620
Mailing Address - Country:US
Mailing Address - Phone:847-315-2500
Mailing Address - Fax:
Practice Address - Street 1:3416 DEER VALLEY RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-6650
Practice Address - Country:US
Practice Address - Phone:925-978-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH78597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty