Provider Demographics
NPI:1700155769
Name:KOPACKI, MATTHEW H (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:H
Last Name:KOPACKI
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 1:191 ROCK RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-1706
Mailing Address - Country:US
Mailing Address - Phone:201-444-4190
Mailing Address - Fax:201-444-2698
Practice Address - Street 1:191 ROCK RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1706
Practice Address - Country:US
Practice Address - Phone:201-444-4190
Practice Address - Fax:201-444-2698
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI1990300183500000X
MAPH20591183500000X
MEPR4238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist