Provider Demographics
NPI:1578864971
Name:VESTAL, MATT P (RPH)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:P
Last Name:VESTAL
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 1:637 W ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS
Mailing Address - State:AZ
Mailing Address - Zip Code:86046-2334
Mailing Address - Country:US
Mailing Address - Phone:928-635-5977
Mailing Address - Fax:928-635-5984
Practice Address - Street 1:637 W ROUTE 66
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:AZ
Practice Address - Zip Code:86046-2334
Practice Address - Country:US
Practice Address - Phone:928-635-5977
Practice Address - Fax:928-635-5984
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ8648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist