Healthcare Provider Details

I. General information

NPI: 1922732650
Provider Name (Legal Business Name): ANDREW MATHES PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2022
Last Update Date: 07/09/2022
Certification Date: 07/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 DEINHARD LN
MCCALL ID
83638-4800
US

IV. Provider business mailing address

6928 N MOON DRUMMER WAY
MERIDIAN ID
83646-4851
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-4929
  • Fax:
Mailing address:
  • Phone: 208-871-8258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP10077
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: