Provider Demographics
NPI:1588835029
Name:BALLIET, MATTHEW HARRY
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:HARRY
Last Name:BALLIET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801-5815
Mailing Address - Country:US
Mailing Address - Phone:570-286-6644
Mailing Address - Fax:570-286-6733
Practice Address - Street 1:1253 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-5815
Practice Address - Country:US
Practice Address - Phone:570-286-6644
Practice Address - Fax:570-286-6733
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2024-03-05
Deactivation Date:2019-08-21
Deactivation Code:
Reactivation Date:2019-09-18
Provider Licenses
StateLicense IDTaxonomies
PARP-043440-L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist