Provider Demographics
NPI:1609071505
Name:MATTIE, HENRY JAMES (RPH)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:JAMES
Last Name:MATTIE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-2336
Mailing Address - Country:US
Mailing Address - Phone:814-535-5626
Mailing Address - Fax:
Practice Address - Street 1:420 WAYNE ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2336
Practice Address - Country:US
Practice Address - Phone:814-535-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP027497L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP027497LOtherPHARMACIST LICENSE