=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609071505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY JAMES MATTIE RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 WAYNE ST
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15905-2336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-535-5626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 WAYNE ST
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15905-2336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-535-5626
-----------------------------------------------------
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 | RP027497L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------