Provider Demographics
NPI:1215537097
Name:DOUGLAS, MATTHEW (PHARMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DOUGLAS
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 1:492 SW HERSCHEL CT
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-3768
Mailing Address - Country:US
Mailing Address - Phone:386-466-9311
Mailing Address - Fax:
Practice Address - Street 1:14500 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-7858
Practice Address - Country:US
Practice Address - Phone:904-964-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46341183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS46341OtherSTATE LICENSE