Provider Demographics
NPI:1932653821
Name:MATAMOROS, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:MATAMOROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-2831
Mailing Address - Country:US
Mailing Address - Phone:208-478-8510
Mailing Address - Fax:208-235-1328
Practice Address - Street 1:911 N MAIN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-2831
Practice Address - Country:US
Practice Address - Phone:208-478-8510
Practice Address - Fax:208-235-1328
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist