Provider Demographics
NPI:1437709904
Name:MATALAVAGE, LOIS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LOIS
Middle Name:
Last Name:MATALAVAGE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:WENONAH
Mailing Address - State:NJ
Mailing Address - Zip Code:08090-2049
Mailing Address - Country:US
Mailing Address - Phone:609-457-2200
Mailing Address - Fax:
Practice Address - Street 1:1412 N DUPONT HWY
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-1844
Practice Address - Country:US
Practice Address - Phone:302-328-3175
Practice Address - Fax:302-328-4365
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0004000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist