Provider Demographics
NPI:1477169779
Name:MCCULLOUGH, MATTHEW (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15826 RUSHFORD ST
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90603-2860
Mailing Address - Country:US
Mailing Address - Phone:562-947-8473
Mailing Address - Fax:
Practice Address - Street 1:15466 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-1301
Practice Address - Country:US
Practice Address - Phone:562-943-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist