Healthcare Provider Details

I. General information

NPI: 1093542995
Provider Name (Legal Business Name): KPAH CHARLES MATADI JR. PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BURDICK EXPY E STE 201
MINOT ND
58701-4769
US

IV. Provider business mailing address

1909 31ST AVE SW APT 450
MINOT ND
58701-7465
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-7900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH6594
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: