Healthcare Provider Details

I. General information

NPI: 1871265348
Provider Name (Legal Business Name): MATTHEW EDWARD COTHRON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 E 12 MILE RD
WARREN MI
48092-5642
US

IV. Provider business mailing address

8529 HARDING
CENTER LINE MI
48015-1557
US

V. Phone/Fax

Practice location:
  • Phone: 586-751-3600
  • Fax: 586-751-1257
Mailing address:
  • Phone: 248-238-6874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303007534
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: