Provider Demographics
NPI:1467032789
Name:SHORT, MATTHEW SCOTT (PHARM D)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SCOTT
Last Name:SHORT
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1720
Mailing Address - Country:US
Mailing Address - Phone:765-362-1139
Mailing Address - Fax:
Practice Address - Street 1:106 E MARKET ST
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1720
Practice Address - Country:US
Practice Address - Phone:765-362-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020136A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26020136AOtherSTATE LICENSE