Provider Demographics
NPI:1912284613
Name:MATUTAT, ROBERT JOHN (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOHN
Last Name:MATUTAT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 W PORTAL AVE
Mailing Address - Street 2:NO. 182
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1304
Mailing Address - Country:US
Mailing Address - Phone:415-699-2253
Mailing Address - Fax:415-869-3920
Practice Address - Street 1:58 W PORTAL AVE
Practice Address - Street 2:NO. 182
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1304
Practice Address - Country:US
Practice Address - Phone:415-699-2253
Practice Address - Fax:415-869-3920
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist