Healthcare Provider Details

I. General information

NPI: 1659914976
Provider Name (Legal Business Name): DOUGLAS ERIC MATHEWS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10305 S 1300 E
SANDY UT
84094-4681
US

IV. Provider business mailing address

2342 E BEAR HILLS DR
DRAPER UT
84020-9672
US

V. Phone/Fax

Practice location:
  • Phone: 801-572-1398
  • Fax: 801-572-8806
Mailing address:
  • Phone: 801-571-6269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number150813-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: