Provider Demographics
NPI:1255873618
Name:MATHEW, SANJUSHA ELSY
Entity type:Individual
Prefix:
First Name:SANJUSHA
Middle Name:ELSY
Last Name:MATHEW
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 1:12026 ELIZABETH MADISON CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6130
Mailing Address - Country:US
Mailing Address - Phone:469-789-4333
Mailing Address - Fax:
Practice Address - Street 1:1326 WARD BLVD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4665
Practice Address - Country:US
Practice Address - Phone:252-237-5126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist