Provider Demographics
NPI:1861089799
Name:RENZI, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RENZI
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 1:101 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1602
Mailing Address - Country:US
Mailing Address - Phone:570-457-2182
Mailing Address - Fax:570-457-4684
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1602
Practice Address - Country:US
Practice Address - Phone:570-457-2182
Practice Address - Fax:570-457-4684
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP445827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist