=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750004164
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW DIMETROSKY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10600 FRANKSTOWN RD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15235-3074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-241-3348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3118 ANTHEO CT
-----------------------------------------------------
City | MURRYSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15668-1333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-907-3613
-----------------------------------------------------
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 | RP451006
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------