Provider Demographics
NPI:1083388292
Name:MATSON, STUART
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:MATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 E FLAMINGO AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-9203
Mailing Address - Country:US
Mailing Address - Phone:208-205-0660
Mailing Address - Fax:208-205-0662
Practice Address - Street 1:4400 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9203
Practice Address - Country:US
Practice Address - Phone:208-205-0660
Practice Address - Fax:208-205-0662
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist