MEDICARE: MATTHEW O'CONNOR

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	033.0003717	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	033.0003717	OTHER	VT	STATE LICENSE

General Provider Information

NPI Number	:	1982051066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW O'CONNOR

Provider Business Mailing Address
First Line	:	90 CENTER RD
Second Line	:
City	:	ESSEX JUNCTION
State	:	VT
Zip	:	05452-2658
Country	:	US
Telephone Number	:	802-879-4155
Fax Number	:	802-878-7448

Provider Business Practice Location Address
First Line	:	90 CENTER RD
Second Line	:
City	:	ESSEX JUNCTION
State	:	VT
Zip	:	05452-2658
Country	:	US
Telephone Number	:	802-879-4155
Fax Number	:	802-878-7448

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

Provider Enumeration Date	:	05/19/2016
Last Update Date	:	05/19/2016

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