Provider Demographics
NPI:1629359740
Name:HALLENBURG, MATTHEW AARON (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AARON
Last Name:HALLENBURG
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 1:5600 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2305
Mailing Address - Country:US
Mailing Address - Phone:773-745-1640
Mailing Address - Fax:
Practice Address - Street 1:5600 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2305
Practice Address - Country:US
Practice Address - Phone:773-745-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist