=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497262836
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW WAYNE GIBBS R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2018
-----------------------------------------------------
Last Update Date | 01/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 W 38TH ST STE 403
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-459-0639
-----------------------------------------------------
Fax | 512-459-3319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7004 WHISPERING CREEK DR
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78736-1935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-484-4915
-----------------------------------------------------
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 | 30470
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------