Provider Demographics
NPI:1518694314
Name:MATTAR, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
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 1:106 CROSSVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7147
Mailing Address - Country:US
Mailing Address - Phone:864-371-2697
Mailing Address - Fax:
Practice Address - Street 1:1232 W WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1243
Practice Address - Country:US
Practice Address - Phone:864-801-2337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist