Provider Demographics
NPI:1821653536
Name:PICKERING, MATTHEW A (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:A
Last Name:PICKERING
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:PICKERING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:3660 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1638
Mailing Address - Country:US
Mailing Address - Phone:801-830-8561
Mailing Address - Fax:
Practice Address - Street 1:1217 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-2221
Practice Address - Country:US
Practice Address - Phone:541-523-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH001749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH001749OtherPHARMACIST LICENSE
ORRPH001749Medicaid