Provider Demographics
NPI:1134732506
Name:BAJSERT, MATHEW STEPHEN
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:STEPHEN
Last Name:BAJSERT
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:PO BOX 1157
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:VA
Mailing Address - Zip Code:22427
Mailing Address - Country:US
Mailing Address - Phone:804-633-5058
Mailing Address - Fax:804-633-0023
Practice Address - Street 1:104 WEST BROADDUS AVENUE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:VA
Practice Address - Zip Code:22427
Practice Address - Country:US
Practice Address - Phone:804-633-5058
Practice Address - Fax:804-633-0023
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist