Gajan Tristan Mathivanan, PHARM.D
Individual provider Active NPI Pharmacist · Angels Camp, CA
NPI 1609485044 · NPPES record last updated Jul 30, 2020
Key facts
- NPI
- 1609485044
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 82486 (CA)
- Practice address
- 230 S Main St
Angels Camp, CA 95222-9359 - Phone
- (209) 736-4623
- NPI assigned
- Jul 30, 2020
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Doctor of Pharmacy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 82486 | CA | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Thrifty Payless Inc | Past |
Accepting new patients | |
| Thrifty Payless Inc | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 82486 | CA | Yes |
Addresses
Primary practice location
230 S Main St
Angels Camp, CA 95222-9359
Mailing address
0756 Williow Springs Dr
Soulsbyville, CA 95372
Phone (314) 604-0368
Other providers in Angels Camp, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 30, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.