Provider Demographics
NPI:1871878181
Name:MATTER, HAIDY
Entity type:Individual
Prefix:
First Name:HAIDY
Middle Name:
Last Name:MATTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11294 GRAND OAK DR
Mailing Address - Street 2:APT#4
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11294 GRAND OAK DR APT 4
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1250
Practice Address - Country:US
Practice Address - Phone:810-771-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist