Provider Demographics
NPI:1962362251
Name:MATLOCK, MARCO PAOLO MIRAL
Entity type:Individual
Prefix:
First Name:MARCO PAOLO
Middle Name:MIRAL
Last Name:MATLOCK
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 1:40042 BRANCA DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-8203
Mailing Address - Country:US
Mailing Address - Phone:301-305-9032
Mailing Address - Fax:
Practice Address - Street 1:1631 DUAL HWY
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6545
Practice Address - Country:US
Practice Address - Phone:301-305-9032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-18
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30665183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist