Provider Demographics
NPI:1518348242
Name:MATTAR, EDDY
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:
Last Name:MATTAR
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 1:616 SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-9278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:616 SOUTHGATE DR
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-9278
Practice Address - Country:US
Practice Address - Phone:803-272-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist