Provider Demographics
NPI:1336809490
Name:MATTA, MADONNA (RPH)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:
Last Name:MATTA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 ELLINWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2636
Mailing Address - Country:US
Mailing Address - Phone:727-488-8684
Mailing Address - Fax:
Practice Address - Street 1:4337 ELLINWOOD BLVD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-2636
Practice Address - Country:US
Practice Address - Phone:727-488-8684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS63426183500000X
DCPH100003035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist