Provider Demographics
NPI:1982021937
Name:MATYJAS, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MATYJAS
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 1:34 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13417-1456
Mailing Address - Country:US
Mailing Address - Phone:315-768-9609
Mailing Address - Fax:
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-624-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0487691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist