Healthcare Provider Details

I. General information

NPI: 1992179840
Provider Name (Legal Business Name): MATTHEW ALAN KWIATKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

IV. Provider business mailing address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03233198
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: