Provider Demographics
NPI:1275923955
Name:BLACK, MATTHEW (CPHT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45155 FIRST COLONY WAY
Mailing Address - Street 2:ATTN PHARMACY
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-2416
Mailing Address - Country:US
Mailing Address - Phone:301-862-5342
Mailing Address - Fax:
Practice Address - Street 1:45155 FIRST COLONY WAY
Practice Address - Street 2:ATTN PHARMACY
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-2416
Practice Address - Country:US
Practice Address - Phone:301-862-5342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT08958183700000X
VA0230022207183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician