Provider Demographics
NPI:1871265348
Name:COTHRON, MATTHEW EDWARD
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
Last Name:COTHRON
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 1:8529 HARDING
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1557
Mailing Address - Country:US
Mailing Address - Phone:248-238-6874
Mailing Address - Fax:
Practice Address - Street 1:2003 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-5642
Practice Address - Country:US
Practice Address - Phone:586-751-3600
Practice Address - Fax:586-751-1257
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303007534183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician