Provider Demographics
NPI:1629399142
Name:COLEMAN, MATTHEW R (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:COLEMAN
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 1:8177 JERICHO RD
Mailing Address - Street 2:
Mailing Address - City:WEEDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13166-9745
Mailing Address - Country:US
Mailing Address - Phone:315-252-2706
Mailing Address - Fax:
Practice Address - Street 1:6508A BASILE ROWE
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-2942
Practice Address - Country:US
Practice Address - Phone:315-313-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049536183500000X, 1835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835X0200XPharmacy Service ProvidersPharmacistOncology