Provider Demographics
NPI:1578960167
Name:DEMATTEIS, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:DEMATTEIS
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 1:78 OAK ST STE 9
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-1054
Mailing Address - Country:US
Mailing Address - Phone:845-778-1388
Mailing Address - Fax:845-778-3271
Practice Address - Street 1:78 OAK ST STE 9
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:NY
Practice Address - Zip Code:12586-1054
Practice Address - Country:US
Practice Address - Phone:845-778-1388
Practice Address - Fax:845-778-3271
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI058091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist