Provider Demographics
NPI:1063851020
Name:FERNHOLZ, MATTHEW JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:FERNHOLZ
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 1:4344 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7908
Mailing Address - Country:US
Mailing Address - Phone:608-188-8860
Mailing Address - Fax:608-788-5790
Practice Address - Street 1:4344 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7908
Practice Address - Country:US
Practice Address - Phone:608-188-8860
Practice Address - Fax:608-788-5790
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-22
Last Update Date:2013-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12167-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist