Provider Demographics
NPI:1134751548
Name:MATHAI, JAYA MARY
Entity type:Individual
Prefix:
First Name:JAYA
Middle Name:MARY
Last Name:MATHAI
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 1:2045 SOUTH BLVD W
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6540
Mailing Address - Country:US
Mailing Address - Phone:248-879-8322
Mailing Address - Fax:
Practice Address - Street 1:2045 SOUTH BLVD W
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-6540
Practice Address - Country:US
Practice Address - Phone:248-879-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315114492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist