Provider Demographics
NPI:1851852248
Name:PHELPS, MATTHEW N
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:N
Last Name:PHELPS
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 1:16517 STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:HOLLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14470-9016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:259 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1938
Practice Address - Country:US
Practice Address - Phone:585-344-0525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist