Provider Demographics
NPI:1255944823
Name:RUIZ, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RUIZ
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 1:190 N FLORISSANT RD
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-1942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 N FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:FERGUSON
Practice Address - State:MO
Practice Address - Zip Code:63135-1942
Practice Address - Country:US
Practice Address - Phone:314-521-4518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016034607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist