Provider Demographics
NPI:1114777919
Name:MATTSON, AUSTIN LEE
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:LEE
Last Name:MATTSON
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 1:515 E EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1903
Mailing Address - Country:US
Mailing Address - Phone:906-281-4761
Mailing Address - Fax:
Practice Address - Street 1:3610 PLAINFIELD AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-2402
Practice Address - Country:US
Practice Address - Phone:616-365-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351015438183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician