=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811536519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW VAN PHARMD, RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2019
-----------------------------------------------------
Last Update Date | 12/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 W KIMBERLY RD
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52806-5369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-391-1543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4322 EXECUTIVE PKWY APT 418
-----------------------------------------------------
City | WESTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43081-3880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-230-9475
-----------------------------------------------------
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 | 23163
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------