Provider Demographics
NPI:1871721795
Name:MATOS MALLOY, JANNETTE
Entity type:Individual
Prefix:MRS
First Name:JANNETTE
Middle Name:
Last Name:MATOS MALLOY
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 1:617 W 181ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-4937
Mailing Address - Country:US
Mailing Address - Phone:212-923-6912
Mailing Address - Fax:
Practice Address - Street 1:617 W 181ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-4937
Practice Address - Country:US
Practice Address - Phone:212-923-6912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist