Provider Demographics
NPI:1205938990
Name:MATTIOLA, PAUL LOUIS (RPH)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:LOUIS
Last Name:MATTIOLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 TOMPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1743
Mailing Address - Country:US
Mailing Address - Phone:718-727-0426
Mailing Address - Fax:718-816-1803
Practice Address - Street 1:500 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1743
Practice Address - Country:US
Practice Address - Phone:718-727-0426
Practice Address - Fax:718-816-1803
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12030OtherNYS LICENSE NUMBER
NY00259687Medicaid
NY3304312OtherNCPDP NUMBER
NY3304312OtherNCPDP NUMBER