Provider Demographics
NPI:1760080949
Name:STATZ, JOSEPH MATTHEW
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATTHEW
Last Name:STATZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 S DULUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6735
Mailing Address - Country:US
Mailing Address - Phone:605-338-4764
Mailing Address - Fax:
Practice Address - Street 1:1900 S MARION RD
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-3636
Practice Address - Country:US
Practice Address - Phone:605-361-3347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist