Provider Demographics
NPI:1043749385
Name:FEDERICO, MATT JOSEPH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:JOSEPH
Last Name:FEDERICO
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 1:26 GILCREST DR
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-1973
Mailing Address - Country:US
Mailing Address - Phone:401-828-9793
Mailing Address - Fax:
Practice Address - Street 1:1155 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-4830
Practice Address - Country:US
Practice Address - Phone:401-828-9793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH4967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRPH4967OtherRI DEPARTMENT OF HEALTH