Provider Demographics
NPI:1265821979
Name:STAUB, MATTHEW (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:STAUB
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 1:1566 BELLA CRUZ DR
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8969
Mailing Address - Country:US
Mailing Address - Phone:352-205-1780
Mailing Address - Fax:
Practice Address - Street 1:1566 BELLA CRUZ DR
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8969
Practice Address - Country:US
Practice Address - Phone:352-750-9863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist