Healthcare Provider Details

I. General information

NPI: 1427453588
Provider Name (Legal Business Name): MATTHEW BOSTWICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 N DIVISION ST
SPOKANE WA
99208-1211
US

IV. Provider business mailing address

3210 E 44TH AVE APT G304
SPOKANE WA
99223-7756
US

V. Phone/Fax

Practice location:
  • Phone: 509-489-6010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberIR60246805
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: