Provider Demographics
NPI:1366045098
Name:MATHEW, MERLINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MERLINE
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 PIPELINE RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-7326
Mailing Address - Country:US
Mailing Address - Phone:817-282-2581
Mailing Address - Fax:
Practice Address - Street 1:2051 HALL JOHNSON RD
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8735
Practice Address - Country:US
Practice Address - Phone:817-410-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366546178OtherCVS PHARMACY