Provider Demographics
NPI:1235520644
Name:HAAS, MATTIE ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:ANN
Last Name:HAAS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:NAUVOO
Mailing Address - State:IL
Mailing Address - Zip Code:62354-0248
Mailing Address - Country:US
Mailing Address - Phone:217-453-2717
Mailing Address - Fax:217-453-6456
Practice Address - Street 1:1350 MULHOLLAND ST
Practice Address - Street 2:
Practice Address - City:NAUVOO
Practice Address - State:IL
Practice Address - Zip Code:62354-1010
Practice Address - Country:US
Practice Address - Phone:217-453-2717
Practice Address - Fax:217-453-6456
Is Sole Proprietor?:No
Enumeration Date:2015-02-08
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21966183500000X
IL051.297378183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist