Provider Demographics
NPI:1114932787
Name:MATSON, KEELEY MICHELLE (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:KEELEY
Middle Name:MICHELLE
Last Name:MATSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:MISS
Other - First Name:KEELEY
Other - Middle Name:MICHELLE
Other - Last Name:TREVIRANUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:211 N CROCKER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1706
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14409-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist