Provider Demographics
NPI:1932324514
Name:GRAMMER, MATTHEW PAUL (RPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:GRAMMER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939-2161
Mailing Address - Country:US
Mailing Address - Phone:618-995-1346
Mailing Address - Fax:
Practice Address - Street 1:4500 PRISON RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-9011
Practice Address - Country:US
Practice Address - Phone:618-964-1441
Practice Address - Fax:618-964-2064
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7758183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist