Provider Demographics
NPI:1225337470
Name:MATZKIW, MARK ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:MATZKIW
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 1:301 S ELLINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-3454
Mailing Address - Country:US
Mailing Address - Phone:931-359-2890
Mailing Address - Fax:931-359-3396
Practice Address - Street 1:301 S ELLINGTON PKWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-3454
Practice Address - Country:US
Practice Address - Phone:931-359-2980
Practice Address - Fax:931-359-3396
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist