Provider Demographics
NPI:1669749875
Name:BAKOS, MATTHEW RYAN
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:BAKOS
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 1:17739 LONG POINT DR
Mailing Address - Street 2:
Mailing Address - City:REDINGTON SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33708-1239
Mailing Address - Country:US
Mailing Address - Phone:614-390-6572
Mailing Address - Fax:
Practice Address - Street 1:17739 LONG POINT DR
Practice Address - Street 2:
Practice Address - City:REDINGTON SHORES
Practice Address - State:FL
Practice Address - Zip Code:33708-1239
Practice Address - Country:US
Practice Address - Phone:614-390-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS48149183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist