Provider Demographics
NPI:1881985141
Name:KOTCH, MATT S
Entity type:Individual
Prefix:MR
First Name:MATT
Middle Name:S
Last Name:KOTCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2380 CARLYLE PLACE DR
Mailing Address - Street 2:APT 104
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5063
Mailing Address - Country:US
Mailing Address - Phone:336-293-8379
Mailing Address - Fax:336-884-1260
Practice Address - Street 1:1050 MALL LOOP RD
Practice Address - Street 2:TARGET PHARMACY 1079
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7656
Practice Address - Country:US
Practice Address - Phone:336-884-1260
Practice Address - Fax:336-884-1260
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist