Provider Demographics
NPI:1205142734
Name:MATTOCKS, KEITH (PHARM D)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MATTOCKS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BEEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78102-5613
Mailing Address - Country:US
Mailing Address - Phone:361-358-3737
Mailing Address - Fax:361-358-4783
Practice Address - Street 1:100 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BEEVILLE
Practice Address - State:TX
Practice Address - Zip Code:78102-5613
Practice Address - Country:US
Practice Address - Phone:361-358-3737
Practice Address - Fax:361-358-4783
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-21
Last Update Date:2010-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist