Individual
MR. MATTHEW JAY CARLISLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
R.PH.
Contact information
Practice address
1032 CROSSWINDS CT, WENTZVILLE, MO 63385-4836
(636) 327-3560
Mailing address
1032 CROSSWINDS CT, WENTZVILLE, MO 63385-4836
(636) 327-3560
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
051035160
IL
183500000X
Pharmacist
Primary
090974
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
040974
MISSOURI STATE BOARD OF PHARMACY
MO
01
—
051035160
ILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION - PHARMACIST
IL
Enumeration date
12/11/2018
Last updated
12/11/2018
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