Provider Demographics
NPI:1417247438
Name:MATRIANO-LIM, BOB JOHN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:JOHN
Last Name:MATRIANO-LIM
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 1:204 SILVER FOX CIR
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-7704
Mailing Address - Country:US
Mailing Address - Phone:318-564-8880
Mailing Address - Fax:
Practice Address - Street 1:1850 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5212
Practice Address - Country:US
Practice Address - Phone:318-222-2972
Practice Address - Fax:318-222-1889
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist