Provider Demographics
NPI:1437759826
Name:MATHEW, LIJI SUSAN
Entity Type:Individual
Prefix:
First Name:LIJI
Middle Name:SUSAN
Last Name:MATHEW
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 1:494 I 30 E
Mailing Address - Street 2:
Mailing Address - City:ROYSE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75189-7527
Mailing Address - Country:US
Mailing Address - Phone:972-635-2734
Mailing Address - Fax:972-635-2731
Practice Address - Street 1:494 I 30 E
Practice Address - Street 2:
Practice Address - City:ROYSE CITY
Practice Address - State:TX
Practice Address - Zip Code:75189-7527
Practice Address - Country:US
Practice Address - Phone:972-635-2734
Practice Address - Fax:972-635-2731
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist