Provider Demographics
NPI:1811558703
Name:MATANDA MATANDA, ETIENNE JEAN DE DIEU
Entity Type:Individual
Prefix:
First Name:ETIENNE
Middle Name:JEAN DE DIEU
Last Name:MATANDA MATANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 S KONA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-3481
Mailing Address - Country:US
Mailing Address - Phone:254-366-1507
Mailing Address - Fax:
Practice Address - Street 1:14967 W WHITESBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:KERMAN
Practice Address - State:CA
Practice Address - Zip Code:93630-1111
Practice Address - Country:US
Practice Address - Phone:559-842-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist