Provider Demographics
NPI:1831483163
Name:MATULLE, MATTHEW (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MATULLE
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 1:6560 E STATE ST
Mailing Address - Street 2:T-0810
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2545
Mailing Address - Country:US
Mailing Address - Phone:815-227-9777
Mailing Address - Fax:815-227-9777
Practice Address - Street 1:6560 E STATE ST
Practice Address - Street 2:T-0810
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2545
Practice Address - Country:US
Practice Address - Phone:815-227-9777
Practice Address - Fax:815-227-9777
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292187183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist