Provider Demographics
NPI:1083219364
Name:HART, MATTHEW EARL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EARL
Last Name:HART
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 S BROOKS DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-0466
Mailing Address - Country:US
Mailing Address - Phone:816-803-0398
Mailing Address - Fax:
Practice Address - Street 1:919 HIGHWAY D
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3169
Practice Address - Country:US
Practice Address - Phone:573-348-5963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020020034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020020034OtherMISSOURI BOARD OF PHARMACY