=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518089069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATOAKEE SKINNER WELLMAN RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 W 21ST ST
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23517-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-627-5588
-----------------------------------------------------
Fax | 757-533-9412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 COPPER STONE CIR
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-8273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-547-2101
-----------------------------------------------------
Fax | 757-547-4331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202009174
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------