Provider Demographics
NPI:1932427093
Name:DEMATERA, MAILEEN (RPH)
Entity Type:Individual
Prefix:MISS
First Name:MAILEEN
Middle Name:
Last Name:DEMATERA
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 1:1097 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-4126
Mailing Address - Country:US
Mailing Address - Phone:201-436-6831
Mailing Address - Fax:
Practice Address - Street 1:1097 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4126
Practice Address - Country:US
Practice Address - Phone:201-436-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02951400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist