Provider Demographics
NPI:1275819856
Name:TAYLOR, MATTHEW A (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:A
Last Name:TAYLOR
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 1:3990 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1527
Mailing Address - Country:US
Mailing Address - Phone:810-987-4679
Mailing Address - Fax:810-987-4694
Practice Address - Street 1:3990 24TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-1527
Practice Address - Country:US
Practice Address - Phone:810-987-4679
Practice Address - Fax:810-987-4694
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302028116OtherSTATE OF MICHIGAN BOARD OF PHARMACY