Provider Demographics
NPI:1770041758
Name:MATLI, CHARLES ELIAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ELIAS
Last Name:MATLI
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 1:3134 SUMMER DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6726
Mailing Address - Country:US
Mailing Address - Phone:917-748-5678
Mailing Address - Fax:
Practice Address - Street 1:JUNCTION OF HWY 371 AND NAVAJO SERVICE ROUTE 9
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313
Practice Address - Country:US
Practice Address - Phone:505-786-6344
Practice Address - Fax:505-786-2526
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist