=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497147862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW BRENDAN BUDKE PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2015
-----------------------------------------------------
Last Update Date | 09/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11039 HUNTWICKE PL
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45241-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-604-2047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11039 HUNTWICKE PL
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45241-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-604-2047
-----------------------------------------------------
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 | 016491
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03232808
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------