Provider Demographics
NPI:1295335628
Name:PALAMATTATHIL, MATHAI
Entity type:Individual
Prefix:
First Name:MATHAI
Middle Name:
Last Name:PALAMATTATHIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6588 DABNEY ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1100
Mailing Address - Country:US
Mailing Address - Phone:239-823-1996
Mailing Address - Fax:
Practice Address - Street 1:11225 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1639
Practice Address - Country:US
Practice Address - Phone:239-591-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist