Provider Demographics
NPI:1639448426
Name:TATUM, MAYA ANGELA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MAYA
Middle Name:ANGELA
Last Name:TATUM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1921
Mailing Address - Country:US
Mailing Address - Phone:267-773-8651
Mailing Address - Fax:
Practice Address - Street 1:701 N WALES RD
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-2754
Practice Address - Country:US
Practice Address - Phone:215-412-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARPI005647183500000X
PARP4411171835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist