Healthcare Provider Details

I. General information

NPI: 1982138749
Provider Name (Legal Business Name): MATTHEW TROYER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 13TH AVE
FARGO ND
58103
US

IV. Provider business mailing address

2425 13TH AVE S
FARGO ND
58103-3749
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-4872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH5458
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: