Healthcare Provider Details

I. General information

NPI: 1295920403
Provider Name (Legal Business Name): MATRIX RX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 MACE AVE
BALTIMORE MD
21221-3315
US

IV. Provider business mailing address

1025 FOXRIDGE LN
BALTIMORE MD
21221-5914
US

V. Phone/Fax

Practice location:
  • Phone: 443-600-7466
  • Fax:
Mailing address:
  • Phone: 443-600-7466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberM03406
License Number StateMD

VIII. Authorized Official

Name: MS. SHERRI FUGET
Title or Position: OFFICE MANAGER
Credential: C.M.T.
Phone: 443-600-7466