Provider Demographics
NPI:1760741003
Name:MATTERA, DONNA G (RPH)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:G
Last Name:MATTERA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7513 SOUTHPORT LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6771
Mailing Address - Country:US
Mailing Address - Phone:217-622-3674
Mailing Address - Fax:217-483-7491
Practice Address - Street 1:1053 JASON PL
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-2018
Practice Address - Country:US
Practice Address - Phone:217-483-7431
Practice Address - Fax:217-483-7491
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist