Provider Demographics
NPI:1063798056
Name:MATSUDA, DALE S (RPH)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:S
Last Name:MATSUDA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37320 FOREST TRL
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:CO
Mailing Address - Zip Code:80107-8109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 S WILCOX ST
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1914
Practice Address - Country:US
Practice Address - Phone:303-663-5998
Practice Address - Fax:303-814-3989
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-23
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist