=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366038226
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW SHAWN PHILLIPS PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2020
-----------------------------------------------------
Last Update Date | 12/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1295 PARKWAY DR
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-1683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-785-1311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 758 N 3500 E
-----------------------------------------------------
City | MENAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83434-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-754-4720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P8508
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------