Provider Demographics
NPI:1497233589
Name:MATHEW, ASHISH K
Entity Type:Individual
Prefix:
First Name:ASHISH
Middle Name:K
Last Name:MATHEW
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 1:1301 CANAL FARM LN APT 5B
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3867
Mailing Address - Country:US
Mailing Address - Phone:408-784-4719
Mailing Address - Fax:
Practice Address - Street 1:1575 W PACHECO BLVD
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-8505
Practice Address - Country:US
Practice Address - Phone:209-826-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist