Provider Demographics
NPI:1023745692
Name:CARRILLO, MATEO JESUS (PHARMD)
Entity type:Individual
Prefix:
First Name:MATEO
Middle Name:JESUS
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 VERMELLA WAY
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-1336
Mailing Address - Country:US
Mailing Address - Phone:630-666-9795
Mailing Address - Fax:
Practice Address - Street 1:20 W 36TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-8005
Practice Address - Country:US
Practice Address - Phone:212-675-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist