Provider Demographics
NPI:1134596901
Name:HENDERSON, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HENDERSON
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 1:1026 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1317
Mailing Address - Country:US
Mailing Address - Phone:248-546-4620
Mailing Address - Fax:
Practice Address - Street 1:1026 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1317
Practice Address - Country:US
Practice Address - Phone:248-546-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040885183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist