Healthcare Provider Details

I. General information

NPI: 1770823015
Provider Name (Legal Business Name): MATTHEW P VANCE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2013
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 N HANLEY RD STE B
SAINT LOUIS MO
63134-2715
US

IV. Provider business mailing address

1063 WELLINGTON TER
CHESTERFIELD MO
63017-8345
US

V. Phone/Fax

Practice location:
  • Phone: 866-997-3688
  • Fax:
Mailing address:
  • Phone: 314-488-0876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2009031401
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: