Healthcare Provider Details

I. General information

NPI: 1164705018
Provider Name (Legal Business Name): MR. MATTHEW MOY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 QUINCY AVENUE
QUINCY MA
02184
US

IV. Provider business mailing address

418 QUINCY AVE
QUINCY MA
02169-8130
US

V. Phone/Fax

Practice location:
  • Phone: 617-472-4483
  • Fax:
Mailing address:
  • Phone: 617-472-4483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH27731
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: