Provider Demographics
NPI:1922778117
Name:VOLUNTAD, MATT BRIAN BERMEJO
Entity Type:Individual
Prefix:
First Name:MATT BRIAN
Middle Name:BERMEJO
Last Name:VOLUNTAD
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 1:1701 W ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-2807
Mailing Address - Country:US
Mailing Address - Phone:713-529-2475
Mailing Address - Fax:
Practice Address - Street 1:1701 W ALABAMA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-2807
Practice Address - Country:US
Practice Address - Phone:713-529-2475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX259835183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician