Provider Demographics
NPI:1770187007
Name:MATTESON, GEORGE ROSS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROSS
Last Name:MATTESON
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 1:1014 TROY RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2360
Mailing Address - Country:US
Mailing Address - Phone:217-218-1016
Mailing Address - Fax:
Practice Address - Street 1:3319 NAMEOKI RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3708
Practice Address - Country:US
Practice Address - Phone:217-218-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist