Provider Demographics
NPI:1336142231
Name:RODRIGUEZ, MATTHEW JOHN (DOCTOR OF PHARMACY)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:19 E CHILI LINE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1395
Mailing Address - Country:US
Mailing Address - Phone:505-670-9386
Mailing Address - Fax:505-982-7065
Practice Address - Street 1:1700 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3554
Practice Address - Country:US
Practice Address - Phone:505-946-9387
Practice Address - Fax:505-982-7065
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15772183500000X
NM6554183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist