Provider Demographics
NPI:1255669594
Name:MATARESE, STACEY (RPH)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MATARESE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 W COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78237-1502
Mailing Address - Country:US
Mailing Address - Phone:210-451-0392
Mailing Address - Fax:210-434-7943
Practice Address - Street 1:4703 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-1502
Practice Address - Country:US
Practice Address - Phone:210-434-5566
Practice Address - Fax:210-434-7943
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45674183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist