Healthcare Provider Details

I. General information

NPI: 1679576086
Provider Name (Legal Business Name): MR. HERBERT GRAHAM MATHEWS III
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W BELVEDERE AVE
BALTIMORE MD
21215-5216
US

IV. Provider business mailing address

904 BENTLEY RD
FREELAND MD
21053-9517
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-0674
  • Fax: 410-601-7032
Mailing address:
  • Phone: 410-357-4402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number13250
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number008604
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: