Provider Demographics
NPI:1255542627
Name:MATOS, MILDRED
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:MATOS
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:URB. VILLAS DEL OESTE
Mailing Address - Street 2:CALLE ARIES #677
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682
Mailing Address - Country:US
Mailing Address - Phone:787-833-8168
Mailing Address - Fax:
Practice Address - Street 1:345 CALLE POST S
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-2389
Practice Address - Country:US
Practice Address - Phone:787-831-2212
Practice Address - Fax:787-805-3875
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1977183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician