1962790899 NPI number — DR. MATTHEW R MCCULLOCH PHARM.D

Table of content: MRS. ILIA NICOLE REISMAN M.S. CCC-SLP (NPI 1538460324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962790899 NPI number — DR. MATTHEW R MCCULLOCH PHARM.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOCH
Provider First Name:
MATTHEW
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962790899
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 N GRAND AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOGALES
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85621-1061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-761-2128
Provider Business Mailing Address Fax Number:
520-281-1112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1103 CIRCULO MERCADO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO RICO
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85648-6248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-761-2128
Provider Business Practice Location Address Fax Number:
520-281-1112
Provider Enumeration Date:
07/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P0018X , with the licence number:  S016557 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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