Provider Demographics
NPI:1861834483
Name:MATA-5 INC.
Entity Type:Organization
Organization Name:MATA-5 INC.
Other - Org Name:DEVZ PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WASHDEV
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-335-6312
Mailing Address - Street 1:PO BOX 871249
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6249
Mailing Address - Country:US
Mailing Address - Phone:734-335-6312
Mailing Address - Fax:313-202-8233
Practice Address - Street 1:6624 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1651
Practice Address - Country:US
Practice Address - Phone:734-335-6312
Practice Address - Fax:313-202-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010101403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy