Provider Demographics
NPI:1437505237
Name:MATVIYIVA, ILLIRIYA
Entity Type:Individual
Prefix:
First Name:ILLIRIYA
Middle Name:
Last Name:MATVIYIVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2552
Mailing Address - Country:US
Mailing Address - Phone:813-876-0599
Mailing Address - Fax:
Practice Address - Street 1:1505 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2552
Practice Address - Country:US
Practice Address - Phone:813-876-0599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist