Provider Demographics
NPI:1154622702
Name:FREISE, MATTHEW A (RPH, PHARMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:FREISE
Suffix:
Gender:M
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 NE GLEN OAK AVE
Mailing Address - Street 2:DEPT 7300-PHARMACY
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-0002
Mailing Address - Country:US
Mailing Address - Phone:309-672-4968
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:DEPT 7300-PHARMACY
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0002
Practice Address - Country:US
Practice Address - Phone:309-672-4968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-14
Last Update Date:2010-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist