Provider Demographics
NPI:1861039653
Name:BESSESEN, MATTHEW WILLIAM
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:BESSESEN
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 1:621 COUNTRY SIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-1101
Mailing Address - Country:US
Mailing Address - Phone:260-248-4572
Mailing Address - Fax:260-248-4573
Practice Address - Street 1:621 COUNTRY SIDE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1101
Practice Address - Country:US
Practice Address - Phone:260-248-4572
Practice Address - Fax:260-248-4573
Is Sole Proprietor?:No
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027370A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist