Provider Demographics
NPI:1780302174
Name:SMITH, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SMITH
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 1:1749 N FM 1049
Mailing Address - Street 2:
Mailing Address - City:KNIPPA
Mailing Address - State:TX
Mailing Address - Zip Code:78870-1027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 19TH ST
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-2504
Practice Address - Country:US
Practice Address - Phone:830-426-5312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist