Healthcare Provider Details

I. General information

NPI: 1790042752
Provider Name (Legal Business Name): MATTHEW DAVIDSON PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 E 41ST ST SUITE 2H23
TULSA OK
74135-2536
US

IV. Provider business mailing address

4502 E 41ST ST SUITE 2H23
TULSA OK
74135-2536
US

V. Phone/Fax

Practice location:
  • Phone: 918-660-3018
  • Fax: 918-660-3009
Mailing address:
  • Phone: 918-660-3018
  • Fax: 918-660-3009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number15136
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: