Provider Demographics
NPI:1104645712
Name:MATDAN LJ INC
Entity type:Organization
Organization Name:MATDAN LJ INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSAAD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:760-294-0014
Mailing Address - Street 1:488 E VALLEY PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3324
Mailing Address - Country:US
Mailing Address - Phone:760-294-0014
Mailing Address - Fax:760-294-0066
Practice Address - Street 1:488 E VALLEY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3324
Practice Address - Country:US
Practice Address - Phone:760-294-0014
Practice Address - Fax:760-294-0066
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CARE PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-09
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51469OtherBOARD OF PHARMACY