Provider Demographics
NPI:1720683659
Name:GRAHAM, MATTHEW ROBERT (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 SW MERRYMAN DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-3912
Mailing Address - Country:US
Mailing Address - Phone:816-536-0595
Mailing Address - Fax:
Practice Address - Street 1:11124 HOLMES RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-3625
Practice Address - Country:US
Practice Address - Phone:816-942-3262
Practice Address - Fax:816-942-7660
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019025929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019025929OtherMISSOURI BOARD OF PHARMACY LICENSE NUMBER