MEDICARE: MR. WILLIAM V MATTSON BSRPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	351-030054	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051030054	OTHER	IL	PHARMACIST LICENCE

General Provider Information

NPI Number	:	1750716700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM V MATTSON BSRPH

Provider Business Mailing Address
First Line	:	410 S MEIER RD
Second Line	:
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-2856
Country	:	US
Telephone Number	:	847-981-9077
Fax Number	:

Provider Business Practice Location Address
First Line	:	3330 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1108
Country	:	US
Telephone Number	:	773-348-0027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	09/10/2013

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