Provider Demographics
NPI:1689383119
Name:RUPENA, MATTHEW DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:RUPENA
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 1:14130 TWILIGHT WAY
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3875
Mailing Address - Country:US
Mailing Address - Phone:414-254-0291
Mailing Address - Fax:
Practice Address - Street 1:9100 W BELOIT RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4422
Practice Address - Country:US
Practice Address - Phone:414-254-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21484-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist