Healthcare Provider Details

I. General information

NPI: 1962790899
Provider Name (Legal Business Name): MATTHEW R MCCULLOCH PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 CIRCULO MERCADO
RIO RICO AZ
85648-6248
US

IV. Provider business mailing address

825 N GRAND AVE STE 100
NOGALES AZ
85621-1061
US

V. Phone/Fax

Practice location:
  • Phone: 520-761-2128
  • Fax: 520-281-1112
Mailing address:
  • Phone: 520-761-2128
  • Fax: 520-281-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberS016557
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: