Provider Demographics
NPI:1700480068
Name:MATULLO, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MATULLO
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 1:1965 ROUTE 57
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-3475
Mailing Address - Country:US
Mailing Address - Phone:908-852-7345
Mailing Address - Fax:908-813-1043
Practice Address - Street 1:1965 ROUTE 57
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-3475
Practice Address - Country:US
Practice Address - Phone:908-852-7345
Practice Address - Fax:908-813-1043
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02616500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist