Healthcare Provider Details

I. General information

NPI: 1205861556
Provider Name (Legal Business Name): MATTHEW JAY PAULSON R PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MAIN ST
CARRINGTON ND
58421-1671
US

IV. Provider business mailing address

415 MAIN ST
CARRINGTON ND
58421-1671
US

V. Phone/Fax

Practice location:
  • Phone: 701-652-2521
  • Fax: 701-652-2326
Mailing address:
  • Phone: 701-652-2521
  • Fax: 701-652-2326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4567
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10915
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: