Provider Demographics
NPI:1174846083
Name:JENNINGS, MATTHEW (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HARRY L DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1146
Mailing Address - Country:US
Mailing Address - Phone:607-729-7227
Mailing Address - Fax:607-770-8591
Practice Address - Street 1:650 HARRY L DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1146
Practice Address - Country:US
Practice Address - Phone:607-729-7227
Practice Address - Fax:607-770-8591
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052580OtherPHARMACIST LICENSE #