Provider Demographics
NPI:1467669937
Name:MATUSOVSKY, VLADA
Entity type:Individual
Prefix:
First Name:VLADA
Middle Name:
Last Name:MATUSOVSKY
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 1:3970 BUCK RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-2202
Mailing Address - Country:US
Mailing Address - Phone:215-938-8938
Mailing Address - Fax:
Practice Address - Street 1:ROOM 900 US CUSTOMHOUSE
Practice Address - Street 2:2ND AND CHESTNUT STREETS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106
Practice Address - Country:US
Practice Address - Phone:215-717-3738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP042393L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist