Provider Demographics
NPI:1285665513
Name:FETTMAN, MATTHEW AVERY (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:AVERY
Last Name:FETTMAN
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 1:5148 REBECCA AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-4876
Mailing Address - Country:US
Mailing Address - Phone:330-327-6807
Mailing Address - Fax:
Practice Address - Street 1:2915 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4607
Practice Address - Country:US
Practice Address - Phone:330-454-5151
Practice Address - Fax:330-454-5266
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-25539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist