Provider Demographics
NPI:1750788717
Name:MATSUMURA, SHELLEY REIKO (PHARMD)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:REIKO
Last Name:MATSUMURA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 ARCHGLEN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-1734
Mailing Address - Country:US
Mailing Address - Phone:408-221-8628
Mailing Address - Fax:
Practice Address - Street 1:480 ARCHGLEN WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1734
Practice Address - Country:US
Practice Address - Phone:408-221-8628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH71575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist