Provider Demographics
NPI:1316018419
Name:MATTA, FOUAD A (RPH)
Entity Type:Individual
Prefix:
First Name:FOUAD
Middle Name:A
Last Name:MATTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34644 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5233
Mailing Address - Country:US
Mailing Address - Phone:586-698-0336
Mailing Address - Fax:313-698-0344
Practice Address - Street 1:34644 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5233
Practice Address - Country:US
Practice Address - Phone:586-698-0336
Practice Address - Fax:586-698-0344
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302027183Medicare UPIN