Provider Demographics
NPI:1316354038
Name:MATAMOROS, DEANA
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:
Last Name:MATAMOROS
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 1:705 E DIXON BLVD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152-6821
Mailing Address - Country:US
Mailing Address - Phone:704-484-0051
Mailing Address - Fax:
Practice Address - Street 1:705 E DIXON BLVD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-6821
Practice Address - Country:US
Practice Address - Phone:704-484-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist