Provider Demographics
NPI:1609485044
Name:MATHIVANAN, GAJAN TRISTAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GAJAN
Middle Name:TRISTAN
Last Name:MATHIVANAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0756 WILLIOW SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SOULSBYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95372
Mailing Address - Country:US
Mailing Address - Phone:314-604-0368
Mailing Address - Fax:
Practice Address - Street 1:230 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222-9359
Practice Address - Country:US
Practice Address - Phone:209-736-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist