Provider Demographics
NPI:1174283410
Name:PIERCE, MATTHEW (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PIERCE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:LAWRENCE
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10810 INDIGO CRK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78239-3272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68898183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist