Provider Demographics
NPI:1588235477
Name:FUIT, MATTHEW WAYNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:FUIT
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 1:697 W DAVENPORT ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8140
Mailing Address - Country:US
Mailing Address - Phone:208-995-3419
Mailing Address - Fax:
Practice Address - Street 1:5230 W FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1109
Practice Address - Country:US
Practice Address - Phone:208-439-6433
Practice Address - Fax:208-439-6427
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP9415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist