Provider Demographics
NPI:1346682952
Name:MATA, WASHDEV S (RPH)
Entity Type:Individual
Prefix:MR
First Name:WASHDEV
Middle Name:S
Last Name:MATA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 871249
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6249
Mailing Address - Country:US
Mailing Address - Phone:734-274-1583
Mailing Address - Fax:313-202-8233
Practice Address - Street 1:6624 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1651
Practice Address - Country:US
Practice Address - Phone:734-335-6312
Practice Address - Fax:313-202-8233
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist