Active NPI
Matthew Raymond Illich, PHARMD
- Pharmacist
- Gulfport, MS
National Provider Identifier
1558972307
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 16174
- Practice address
- 1417 E Pass Rd
Gulfport, MS 39507-3522 - Phone
- (228) 896-3870
- NPI assigned
- Aug 14, 2020
- Last updated
- Dec 26, 2022
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 16174 | MS | Primary |
Addresses
Primary practice location
1417 E Pass Rd
Gulfport, MS 39507-3522
Mailing address
905 Sea Cove St
Pascagoula, MS 39581-2166
Other practice location 1
6970 Old Canton Rd
Ridgeland, MS 39157-1229
Phone (601) 956-3844
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Pharmacy
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walgreen Co | Current | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients |
Locations
1417 E Pass Rd
Gulfport, MS 39507
Phone (228) 896-3870
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1597363200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1672012800000",
"number": "1558972307",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "905 SEA COVE ST",
"city": "PASCAGOULA",
"state": "MS",
"postal_code": "395812166"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1417 E PASS RD",
"city": "GULFPORT",
"state": "MS",
"postal_code": "395073522",
"telephone_number": "228-896-3870"
}
],
"practiceLocations": [
{
"address_1": "6970 Old Canton Rd",
"address_purpose": "LOCATION",
"city": "Ridgeland",
"state": "MS",
"postal_code": "391571229",
"country_code": "US",
"telephone_number": "601-956-3844",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "ILLICH",
"first_name": "MATTHEW",
"middle_name": "RAYMOND",
"credential": "PHARMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-08-14",
"last_updated": "2022-12-26",
"certification_date": "2022-12-26",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "MS",
"license": "16174",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Gulfport, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 26, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.