Provider Demographics
NPI:1689022196
Name:WADE, MATTHEW MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:WADE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2898 WESTINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-8196
Mailing Address - Country:US
Mailing Address - Phone:607-796-2673
Mailing Address - Fax:
Practice Address - Street 1:2898 WESTINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8196
Practice Address - Country:US
Practice Address - Phone:607-796-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI061546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist