=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659971893
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW CLINTON HEISHMAN RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2020
-----------------------------------------------------
Last Update Date | 10/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2450 MAIN ST
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-425-9428
-----------------------------------------------------
Fax | 847-425-9431
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 W MARGATE TER UNIT 1W
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-3810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-425-9428
-----------------------------------------------------
Fax | 847-425-9431
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051.297315
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------