Basic Information
| Provider Information | |||||||||
| NPI: | 1255701504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1132 TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437012658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404545666 | ||||||||
| FaxNumber: | 7404527563 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 FOREST AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437012875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404545666 | ||||||||
| FaxNumber: | 7404529514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03334882 | OH | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.