Provider Demographics
NPI:1972812246
Name:MATTSON, ALICIA SHANA (RPH)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:SHANA
Last Name:MATTSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E JIMMIE LEEDS RD
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-4127
Mailing Address - Country:US
Mailing Address - Phone:609-748-2449
Mailing Address - Fax:609-748-0959
Practice Address - Street 1:335 E JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-4127
Practice Address - Country:US
Practice Address - Phone:609-748-2449
Practice Address - Fax:609-748-0959
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02596800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RJ02336OtherSTATE IMMUNIZATION PROVIDER NUMBER
NJ28RI02596800OtherSTATE LICENSE NUMBER