Provider Demographics
NPI:1306212196
Name:MATHEW, CHARLES KANJIRAKATTU (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KANJIRAKATTU
Last Name:MATHEW
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12800 TWIN PINES LN
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-7638
Mailing Address - Country:US
Mailing Address - Phone:405-249-7413
Mailing Address - Fax:
Practice Address - Street 1:7305 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-6122
Practice Address - Country:US
Practice Address - Phone:405-455-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-15
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16179183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist