Provider Demographics
NPI:1295335826
Name:ANTONOVITCH, MATTHEW JOHN (PHARMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:ANTONOVITCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 NEW BRAINTREE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01585-3218
Mailing Address - Country:US
Mailing Address - Phone:413-374-6532
Mailing Address - Fax:
Practice Address - Street 1:352 PALMER RD
Practice Address - Street 2:
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-9740
Practice Address - Country:US
Practice Address - Phone:413-967-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist