Provider Demographics
NPI:1194825778
Name:NOURSE, MATTHEW DONAVON (RPH)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DONAVON
Last Name:NOURSE
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 1:1054 GRAHAM LN
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8759
Mailing Address - Country:US
Mailing Address - Phone:740-820-5687
Mailing Address - Fax:
Practice Address - Street 1:313 CENTER ST
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1706
Practice Address - Country:US
Practice Address - Phone:740-574-2874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-22575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist