Provider Demographics
NPI:1205861556
Name:PAULSON, MATTHEW JAY (R PH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAY
Last Name:PAULSON
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARRINGTON
Mailing Address - State:ND
Mailing Address - Zip Code:58421-1671
Mailing Address - Country:US
Mailing Address - Phone:701-652-2521
Mailing Address - Fax:701-652-2326
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:CARRINGTON
Practice Address - State:ND
Practice Address - Zip Code:58421-1671
Practice Address - Country:US
Practice Address - Phone:701-652-2521
Practice Address - Fax:701-652-2326
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4567183500000X
NV10915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND4567OtherND BOARD OF PHARMACY
NV10915OtherNEVADA BOARD OF PHARMACY