Healthcare Provider Details

I. General information

NPI: 1174203467
Provider Name (Legal Business Name): MATT AMIDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 S MAIN ST
MOAB UT
84532-2596
US

IV. Provider business mailing address

290 S MAIN ST
MOAB UT
84532-2509
US

V. Phone/Fax

Practice location:
  • Phone: 435-313-2012
  • Fax:
Mailing address:
  • Phone: 435-313-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7550499-1701
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: