Provider Demographics
NPI:1760079693
Name:BACCARELLA, MATTHEW ROBERT
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:BACCARELLA
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 1:855 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WIND GAP
Mailing Address - State:PA
Mailing Address - Zip Code:18091-1629
Mailing Address - Country:US
Mailing Address - Phone:610-863-5341
Mailing Address - Fax:
Practice Address - Street 1:855 S BROADWAY
Practice Address - Street 2:
Practice Address - City:WIND GAP
Practice Address - State:PA
Practice Address - Zip Code:18091-1629
Practice Address - Country:US
Practice Address - Phone:610-863-5341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP450660183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist