Provider Demographics
NPI:1164022190
Name:BACTAD, MATT EDRICK C (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATT EDRICK
Middle Name:C
Last Name:BACTAD
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 1:407 N BRENTWOOD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-7126
Mailing Address - Country:US
Mailing Address - Phone:936-639-1748
Mailing Address - Fax:936-639-1750
Practice Address - Street 1:407 N BRENTWOOD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-7126
Practice Address - Country:US
Practice Address - Phone:936-639-1748
Practice Address - Fax:936-639-1750
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist