Healthcare Provider Details

I. General information

NPI: 1295735314
Provider Name (Legal Business Name): MATTHEW R BACKER PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CHILOQUIN BLVD
CHILOQUIN OR
97624-6773
US

IV. Provider business mailing address

3949 S 6TH ST
KLAMATH FALLS OR
97603-4746
US

V. Phone/Fax

Practice location:
  • Phone: 800-552-6290
  • Fax:
Mailing address:
  • Phone: 800-552-6290
  • Fax: 541-880-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11103
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: