Healthcare Provider Details

I. General information

NPI: 1366043770
Provider Name (Legal Business Name): MATTHEW LOPEZ PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4965 HIGHWAY 90
PACE FL
32571-1408
US

IV. Provider business mailing address

4965 HIGHWAY 90
PACE FL
32571-1408
US

V. Phone/Fax

Practice location:
  • Phone: 850-995-5115
  • Fax: 850-995-8979
Mailing address:
  • Phone: 850-995-5115
  • Fax: 850-995-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS43258
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: