Provider Demographics
NPI:1497009021
Name:MATTHEWS, NICOLLE ANNE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:NICOLLE
Middle Name:ANNE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:NICOLLE
Other - Middle Name:ANNE
Other - Last Name:KOESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:321 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1017
Mailing Address - Country:US
Mailing Address - Phone:607-776-6039
Mailing Address - Fax:
Practice Address - Street 1:321 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1017
Practice Address - Country:US
Practice Address - Phone:607-776-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist