Provider Demographics
NPI:1922656321
Name:MATTA, ELIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELIE
Middle Name:
Last Name:MATTA
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 1:5438 HARTWELL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3311
Mailing Address - Country:US
Mailing Address - Phone:313-717-8209
Mailing Address - Fax:
Practice Address - Street 1:5851 MERCURY DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4161
Practice Address - Country:US
Practice Address - Phone:313-441-0194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist