Provider Demographics
NPI:1114747169
Name:VELLIYAMATTAM, SHEETAL SAJU
Entity type:Individual
Prefix:
First Name:SHEETAL
Middle Name:SAJU
Last Name:VELLIYAMATTAM
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 1:16198 CARRS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:MD
Mailing Address - Zip Code:21797-8309
Mailing Address - Country:US
Mailing Address - Phone:443-462-1411
Mailing Address - Fax:
Practice Address - Street 1:3779 BOSTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5752
Practice Address - Country:US
Practice Address - Phone:410-522-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30084183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist