Provider Demographics
NPI:1023225349
Name:COLVIN, MATTHEW ALEXANDER (RPH)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:COLVIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NORTHRIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35951-4226
Mailing Address - Country:US
Mailing Address - Phone:256-891-7887
Mailing Address - Fax:
Practice Address - Street 1:10705 AL HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:IDER
Practice Address - State:AL
Practice Address - Zip Code:35981-4627
Practice Address - Country:US
Practice Address - Phone:256-657-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL13798OtherSTATE LICENSE NUMBER