Provider Demographics
NPI:1053916288
Name:HINES, MATTHEW RUSSELL
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RUSSELL
Last Name:HINES
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 1:1550 GEZON PKWY SW STE E-101
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9397
Mailing Address - Country:US
Mailing Address - Phone:517-712-5376
Mailing Address - Fax:
Practice Address - Street 1:2400 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8585
Practice Address - Country:US
Practice Address - Phone:517-548-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist