Provider Demographics
NPI:1619577012
Name:BIRD, MATTHEW THOMAS
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BIRD
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 1:29 VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-7061
Mailing Address - Country:US
Mailing Address - Phone:870-917-5799
Mailing Address - Fax:
Practice Address - Street 1:1123 HIGHWAY 79 167 BYP
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-1810
Practice Address - Country:US
Practice Address - Phone:870-352-8034
Practice Address - Fax:870-352-8337
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist