Provider Demographics
NPI:1760768048
Name:PETRUS, MATTHEW JAMES (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:PETRUS
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 1:1433 W BURNHAM ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3251
Mailing Address - Country:US
Mailing Address - Phone:414-672-3017
Mailing Address - Fax:414-672-3325
Practice Address - Street 1:1433 W BURNHAM ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3251
Practice Address - Country:US
Practice Address - Phone:414-672-3017
Practice Address - Fax:414-672-3325
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15248-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist