Provider Demographics
NPI:1619584745
Name:VANGILDER, MATTHEW
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:VANGILDER
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 1:701 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-3225
Mailing Address - Country:US
Mailing Address - Phone:304-624-0161
Mailing Address - Fax:
Practice Address - Street 1:701 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-3225
Practice Address - Country:US
Practice Address - Phone:304-624-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist