Basic Information
| Provider Information | |||||||||
| NPI: | 1427395128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | TYLER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2875 UNIVERSITY BLVD W | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047307589 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2875 UNIVERSITY BLVD W | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047307589 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2013 | ||||||||
| LastUpdateDate: | 01/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS49001 | FL | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.