Provider Demographics
NPI:1568727303
Name:NYSWONGER, MATTHEW RAND (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RAND
Last Name:NYSWONGER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 COMMONS PL
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-3001
Mailing Address - Country:US
Mailing Address - Phone:785-770-3871
Mailing Address - Fax:
Practice Address - Street 1:800 COMMONS PL
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-3001
Practice Address - Country:US
Practice Address - Phone:785-770-3871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-12326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1-12326OtherKANSAS STATE PHARMACY LICENSE NUMBER