Healthcare Provider Details

I. General information

NPI: 1528562634
Provider Name (Legal Business Name): MATTHEW DARNELL GARDNER CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S LANCASTER RD
DALLAS TX
75216-7167
US

IV. Provider business mailing address

4500 S LANCASTER RD
DALLAS TX
75216-7167
US

V. Phone/Fax

Practice location:
  • Phone: 214-742-8387
  • Fax:
Mailing address:
  • Phone: 214-742-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number209328
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: