Provider Demographics
NPI:1255626131
Name:MATA, AUDRA M (PHARMD)
Entity type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:M
Last Name:MATA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 SW MILITARY DR
Mailing Address - Street 2:T-0771
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-1032
Mailing Address - Country:US
Mailing Address - Phone:210-927-4752
Mailing Address - Fax:210-927-4752
Practice Address - Street 1:2810 SW MILITARY DR
Practice Address - Street 2:T-0771
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1032
Practice Address - Country:US
Practice Address - Phone:210-927-4752
Practice Address - Fax:210-927-4752
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-18
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX49086183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist