Provider Demographics
NPI:1548529613
Name:MATHEW, MOHAN (RPH)
Entity type:Individual
Prefix:MR
First Name:MOHAN
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3812
Mailing Address - Country:US
Mailing Address - Phone:201-432-5205
Mailing Address - Fax:
Practice Address - Street 1:2260 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-3812
Practice Address - Country:US
Practice Address - Phone:201-432-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02010600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist