Provider Demographics
NPI:1134413032
Name:GILDEA, MATT (RPH)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:GILDEA
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 1:6775 ROOSEVELT PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-8946
Mailing Address - Country:US
Mailing Address - Phone:513-422-7313
Mailing Address - Fax:
Practice Address - Street 1:6775 ROOSEVELT PKWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-8946
Practice Address - Country:US
Practice Address - Phone:513-422-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03327072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist