=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831824325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JAMES SPENCER PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2022
-----------------------------------------------------
Last Update Date | 07/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 HIGHWAY 20 N
-----------------------------------------------------
City | HINES
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97738-9435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-573-1523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 HIGHWAY 20 N
-----------------------------------------------------
City | HINES
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97738-9435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-573-1523
-----------------------------------------------------
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 | P10118
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------