Provider Demographics
NPI:1417262452
Name:JOHN, SANIL MATHEW
Entity Type:Individual
Prefix:MR
First Name:SANIL
Middle Name:MATHEW
Last Name:JOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S CLAY ST
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-4519
Mailing Address - Country:US
Mailing Address - Phone:972-875-8313
Mailing Address - Fax:972-875-8377
Practice Address - Street 1:101 S CLAY ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4519
Practice Address - Country:US
Practice Address - Phone:972-875-8313
Practice Address - Fax:972-875-8377
Is Sole Proprietor?:No
Enumeration Date:2010-08-14
Last Update Date:2010-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist