Provider Demographics
NPI:1811543366
Name:GOTFRYD, MATTHEW (PHARMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GOTFRYD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 12TH ST STE 605
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2850
Mailing Address - Country:US
Mailing Address - Phone:708-912-7642
Mailing Address - Fax:
Practice Address - Street 1:1300 N 12TH ST STE 605
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2850
Practice Address - Country:US
Practice Address - Phone:303-452-8661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0022803183500000X
AZS0245831835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist