Basic Information
| Provider Information | |||||||||
| NPI: | 1619577012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 VALLEY CT | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721507061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709175799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1123 HIGHWAY 79 167 BYP | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717421810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703528034 | ||||||||
| FaxNumber: | 8703528337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2020 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PD12866 | AR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.