Provider Demographics
NPI:1902181118
Name:GUMM, MATTHEW JACOB (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JACOB
Last Name:GUMM
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 1:401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-1101
Mailing Address - Country:US
Mailing Address - Phone:608-850-6203
Mailing Address - Fax:608-850-6207
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-1101
Practice Address - Country:US
Practice Address - Phone:608-850-6203
Practice Address - Fax:608-850-6207
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14717-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist