Healthcare Provider Details

I. General information

NPI: 1972969178
Provider Name (Legal Business Name): MATTHEW SONG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 15TH AVE W
WILLISTON ND
58801-3800
US

IV. Provider business mailing address

1301 15TH AVE W
WILLISTON ND
58801-3821
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-7477
  • Fax:
Mailing address:
  • Phone: 701-774-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH5669
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: