Provider Demographics
NPI:1386224848
Name:WIMS, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WIMS
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 1:1616 N ALABAMA RD
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-3204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1616 N ALABAMA RD
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-3204
Practice Address - Country:US
Practice Address - Phone:979-282-2883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX169116183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician