Provider Demographics
NPI:1811599228
Name:TOURDOT, MATTHEW KOEHLER (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:KOEHLER
Last Name:TOURDOT
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 1:123 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1344
Mailing Address - Country:US
Mailing Address - Phone:608-847-5949
Mailing Address - Fax:
Practice Address - Street 1:123 E STATE ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1344
Practice Address - Country:US
Practice Address - Phone:608-847-5949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist