Provider Demographics
NPI:1891945283
Name:MATSTE INC
Entity Type:Organization
Organization Name:MATSTE INC
Other - Org Name:THE HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-319-3926
Mailing Address - Street 1:8571 FOXWOOD CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-4313
Mailing Address - Country:US
Mailing Address - Phone:330-318-3926
Mailing Address - Fax:330-318-3927
Practice Address - Street 1:7160 WARREN SHARON RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:OH
Practice Address - Zip Code:44403-9657
Practice Address - Country:US
Practice Address - Phone:330-448-8009
Practice Address - Fax:330-448-8029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHRTP.0218955003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102317220-0001Medicaid
2117293OtherPK
OH2916910Medicaid
6364070001Medicare NSC
H524030Medicare PIN