Provider Demographics
NPI:1619577236
Name:MATHEW, SHIBU (RPH)
Entity Type:Individual
Prefix:MR
First Name:SHIBU
Middle Name:
Last Name:MATHEW
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 1:14672 FOXBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-1204
Mailing Address - Country:US
Mailing Address - Phone:214-402-5420
Mailing Address - Fax:
Practice Address - Street 1:8621 OHIO DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2264
Practice Address - Country:US
Practice Address - Phone:469-633-0041
Practice Address - Fax:469-633-0043
Is Sole Proprietor?:No
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist