Provider Demographics
NPI:1982998233
Name:ETHEREDGE, MATTHEW D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:ETHEREDGE
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 1:2950 S BLUE ANGEL PKWY
Mailing Address - Street 2:T-2445
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-6905
Mailing Address - Country:US
Mailing Address - Phone:850-454-3001
Mailing Address - Fax:850-454-3011
Practice Address - Street 1:2950 S BLUE ANGEL PKWY
Practice Address - Street 2:T-2445
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-6905
Practice Address - Country:US
Practice Address - Phone:850-454-3001
Practice Address - Fax:850-454-3011
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist