Provider Demographics
NPI:1508311184
Name:MATTU, VIPPAN
Entity Type:Individual
Prefix:
First Name:VIPPAN
Middle Name:
Last Name:MATTU
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 1:1624 DANBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1611
Mailing Address - Country:US
Mailing Address - Phone:530-675-4258
Mailing Address - Fax:
Practice Address - Street 1:1055 MARTIN CT
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-9739
Practice Address - Country:US
Practice Address - Phone:530-329-3082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73796183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist