Provider Demographics
NPI:1255098398
Name:SWAN, MATT
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:SWAN
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:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:WADLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30477-0069
Mailing Address - Country:US
Mailing Address - Phone:478-252-5252
Mailing Address - Fax:
Practice Address - Street 1:48 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WADLEY
Practice Address - State:GA
Practice Address - Zip Code:30477-3713
Practice Address - Country:US
Practice Address - Phone:478-252-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA32298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist