Provider Demographics
NPI:1982118881
Name:BOURNE, MATT (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:BOURNE
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 1:4700 N HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2700
Mailing Address - Country:US
Mailing Address - Phone:314-475-6000
Mailing Address - Fax:
Practice Address - Street 1:4700 N HANLEY RD
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:MO
Practice Address - Zip Code:63134-2700
Practice Address - Country:US
Practice Address - Phone:314-475-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist