Healthcare Provider Details

I. General information

NPI: 1316420326
Provider Name (Legal Business Name): RYAN JAMES MATTISON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 4TH ST
LONGVIEW TX
75605-5128
US

IV. Provider business mailing address

2109 FAIRFAX LN.
LONGVIEW TX
75605-1111
US

V. Phone/Fax

Practice location:
  • Phone: 903-758-1818
  • Fax:
Mailing address:
  • Phone: 817-988-5691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number70546
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number70546
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: