Provider Demographics
NPI:1609694892
Name:MCCORMLEY, MATTHEW BENJAMIN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BENJAMIN
Last Name:MCCORMLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 JEFFERSONVILLE COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8395
Mailing Address - Country:US
Mailing Address - Phone:812-288-9245
Mailing Address - Fax:
Practice Address - Street 1:1027 JEFFERSONVILLE COMMONS DR
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8395
Practice Address - Country:US
Practice Address - Phone:812-288-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0237873336C0003X
IN26030487A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy