Healthcare Provider Details

I. General information

NPI: 1518443522
Provider Name (Legal Business Name): BRANDON L. MATACIC PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

3326 SW MARQUAM HILL RD UNIT B
PORTLAND OR
97239-1493
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone: 330-720-7202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number03237246
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: