Provider Demographics
NPI:1225247059
Name:JENNISON, MATTHEW R (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:JENNISON
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 1:1930 BRIDGEPOINTE CIR UNIT 51
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32967-6855
Mailing Address - Country:US
Mailing Address - Phone:321-795-3620
Mailing Address - Fax:
Practice Address - Street 1:1255 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5729
Practice Address - Country:US
Practice Address - Phone:772-778-4771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist