Provider Demographics
NPI:1962790899
Name:MCCULLOCH, MATTHEW R (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:R
Last Name:MCCULLOCH
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 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-761-2128
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:1103 CIRCULO MERCADO
Practice Address - Street 2:
Practice Address - City:RIO RICO
Practice Address - State:AZ
Practice Address - Zip Code:85648-6248
Practice Address - Country:US
Practice Address - Phone:520-761-2128
Practice Address - Fax:520-281-1112
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0165571835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist