Provider Demographics
NPI:1245820877
Name:MATARIA, JALAL (RPH)
Entity type:Individual
Prefix:
First Name:JALAL
Middle Name:
Last Name:MATARIA
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 1:222 STONE CT STE C
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1598
Mailing Address - Country:US
Mailing Address - Phone:815-666-1113
Mailing Address - Fax:
Practice Address - Street 1:6700 W 95TH ST STE 150
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2280
Practice Address - Country:US
Practice Address - Phone:708-598-5000
Practice Address - Fax:708-598-6737
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist