Provider Demographics
NPI:1811536519
Name:VAN, MATTHEW (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4322 EXECUTIVE PKWY APT 418
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3880
Mailing Address - Country:US
Mailing Address - Phone:309-230-9475
Mailing Address - Fax:
Practice Address - Street 1:2200 W KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5369
Practice Address - Country:US
Practice Address - Phone:563-391-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist