Provider Demographics
NPI:1265037212
Name:SABU, MATHEW (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:
Last Name:SABU
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 KALLAS CT
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1517
Mailing Address - Country:US
Mailing Address - Phone:516-849-5801
Mailing Address - Fax:
Practice Address - Street 1:462 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5107
Practice Address - Country:US
Practice Address - Phone:516-849-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03805700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY064685OtherLICENSE
NJ28RI03805700OtherLICENSE