Provider Demographics
NPI:1376810481
Name:WEEGE, MATTHEW D (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:WEEGE
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 1:829 E GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-2618
Mailing Address - Country:US
Mailing Address - Phone:262-268-9091
Mailing Address - Fax:262-268-9098
Practice Address - Street 1:829 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2618
Practice Address - Country:US
Practice Address - Phone:262-268-9091
Practice Address - Fax:262-268-9098
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11741-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33273400Medicaid