Provider Demographics
NPI:1730474289
Name:BAUER, MATTHEW JOHN (RPH)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:BAUER
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 1:2652 S SIESTA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2968
Mailing Address - Country:US
Mailing Address - Phone:330-495-3667
Mailing Address - Fax:
Practice Address - Street 1:4700 N EAGLE RD # T1960
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0744
Practice Address - Country:US
Practice Address - Phone:208-939-5149
Practice Address - Fax:208-939-5282
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT98474183500000X
AZS018022183500000X
IDP9887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist