=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881985141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MATT S KOTCH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2011
-----------------------------------------------------
Last Update Date | 04/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 MALL LOOP RD TARGET PHARMACY 1079
-----------------------------------------------------
City | HIGH POINT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27262-7656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-884-1260
-----------------------------------------------------
Fax | 336-884-1260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2380 CARLYLE PLACE DR APT 104
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-5063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-293-8379
-----------------------------------------------------
Fax | 336-884-1260
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 21196
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------