Provider Demographics
NPI:1578193744
Name:BANTZ, MATTHEW EUGENE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EUGENE
Last Name:BANTZ
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 W EDGERTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4420
Mailing Address - Country:US
Mailing Address - Phone:414-421-8401
Mailing Address - Fax:414-855-0748
Practice Address - Street 1:6901 W EDGERTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-4420
Practice Address - Country:US
Practice Address - Phone:414-421-8401
Practice Address - Fax:414-855-0748
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17697183500000X
KS1-106313183500000X
LAPST.021720183500000X
MAPH236166183500000X
MI5302043341183500000X
MD23906183500000X
MST-15141183500000X
NE14885183500000X
OK16880183500000X
TX59136183500000X
VT033.0130667183500000X
WVRP0008529183500000X
WI16320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist