Provider Demographics
NPI:1073117610
Name:GRANT, MATTHEW J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:GRANT
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 1:2561 LAKEFAIR DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-7002
Mailing Address - Country:US
Mailing Address - Phone:850-779-6154
Mailing Address - Fax:
Practice Address - Street 1:1390 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-1636
Practice Address - Country:US
Practice Address - Phone:850-997-4108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist