Provider Demographics
NPI:1629679683
Name:TEAGUE, MATTHEW (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 PORTAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7245
Mailing Address - Country:US
Mailing Address - Phone:330-497-7352
Mailing Address - Fax:
Practice Address - Street 1:4790 PORTAGE ST NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7245
Practice Address - Country:US
Practice Address - Phone:330-497-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03129677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist