Provider Demographics
NPI:1972028314
Name:MATIBAG, MARIA CECILIA (RPH)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:CECILIA
Last Name:MATIBAG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 COMMUNITY AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-2602
Mailing Address - Country:US
Mailing Address - Phone:818-642-6390
Mailing Address - Fax:
Practice Address - Street 1:1400 W KENNETH RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1422
Practice Address - Country:US
Practice Address - Phone:818-242-4158
Practice Address - Fax:818-247-8593
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH69135OtherPHARMACIST LISCENSE