Provider Demographics
NPI:1710254982
Name:BERRY, MATTHEW LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LEE
Last Name:BERRY
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 1:34226 VENICE PARK RD
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1323
Mailing Address - Country:US
Mailing Address - Phone:262-434-0033
Mailing Address - Fax:
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-672-6183
Practice Address - Fax:262-619-0499
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14075-040183500000X
IL051-037143183500000X
MI5302028240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist