Provider Demographics
NPI:1992287346
Name:MATIWALA, ANJANA
Entity type:Individual
Prefix:
First Name:ANJANA
Middle Name:
Last Name:MATIWALA
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 1:1236 BURNHAM STREET
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188
Mailing Address - Country:US
Mailing Address - Phone:630-871-6044
Mailing Address - Fax:
Practice Address - Street 1:1600 MCCONNOR PARKWAY
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60188
Practice Address - Country:US
Practice Address - Phone:215-681-8167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-02
Last Update Date:2018-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.039739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051.039739OtherREGISTERED PHARMACIST