Provider Demographics
NPI:1851724090
Name:MARTINEAU, MATTHEW RAY (PHARM D, RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RAY
Last Name:MARTINEAU
Suffix:
Gender:M
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5764
Mailing Address - Country:US
Mailing Address - Phone:307-635-1155
Mailing Address - Fax:
Practice Address - Street 1:2302 E. LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-635-0241
Practice Address - Fax:307-635-1756
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist