Provider Demographics
NPI:1518290261
Name:MATTSON, EDWARD (PHARM D)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MATTSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3834
Mailing Address - Country:US
Mailing Address - Phone:503-428-5073
Mailing Address - Fax:503-428-5077
Practice Address - Street 1:699 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3834
Practice Address - Country:US
Practice Address - Phone:503-428-5073
Practice Address - Fax:503-428-5077
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0011926183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist