Provider Demographics
NPI:1508125022
Name:MATSON, DWIGHT JOHN
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:JOHN
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 1:3250 LEIF ERIKSON DR
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-2637
Mailing Address - Country:US
Mailing Address - Phone:503-338-0291
Mailing Address - Fax:
Practice Address - Street 1:3250 LEIF ERIKSON DR
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2637
Practice Address - Country:US
Practice Address - Phone:503-338-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0005128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist