Provider Demographics
NPI:1821467184
Name:MATA, DIANA (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10682 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-3324
Mailing Address - Country:US
Mailing Address - Phone:310-948-2157
Mailing Address - Fax:
Practice Address - Street 1:1421 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-5221
Practice Address - Country:US
Practice Address - Phone:714-732-1978
Practice Address - Fax:623-336-6421
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA73520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist