Provider Demographics
NPI:1568936300
Name:MATSUMOTO, JEREMY KANG (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KANG
Last Name:MATSUMOTO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BODIN CIRCLE
Mailing Address - Street 2:BUILDING 777
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535
Mailing Address - Country:US
Mailing Address - Phone:707-423-7194
Mailing Address - Fax:
Practice Address - Street 1:60 MDG/SGQP 101 BODIN CIR
Practice Address - Street 2:BLDG. 777
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-4028
Practice Address - Country:US
Practice Address - Phone:707-423-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023271183500000X
CA79163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist