Healthcare Provider Details

I. General information

NPI: 1881985141
Provider Name (Legal Business Name): MR. MATT S KOTCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 MALL LOOP RD TARGET PHARMACY 1079
HIGH POINT NC
27262-7656
US

IV. Provider business mailing address

2380 CARLYLE PLACE DR APT 104
WINSTON SALEM NC
27103-5063
US

V. Phone/Fax

Practice location:
  • Phone: 336-884-1260
  • Fax: 336-884-1260
Mailing address:
  • Phone: 336-293-8379
  • Fax: 336-884-1260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21196
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: