Provider Demographics
NPI:1821694944
Name:MATEV, DMITRIY (PHARMD)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:MATEV
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 1:210 11TH AVE N APT 202
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-7265
Mailing Address - Country:US
Mailing Address - Phone:904-305-3062
Mailing Address - Fax:
Practice Address - Street 1:13170 ATLANTIC BLVD STE 47
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4150
Practice Address - Country:US
Practice Address - Phone:904-221-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist