Provider Demographics
NPI:1396788741
Name:MABIE, MATTHEW RYAN (RPH)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RYAN
Last Name:MABIE
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 1:2108 UPHOFF RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9475
Mailing Address - Country:US
Mailing Address - Phone:608-347-5420
Mailing Address - Fax:
Practice Address - Street 1:429 W COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9385
Practice Address - Country:US
Practice Address - Phone:608-839-3335
Practice Address - Fax:608-839-3336
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12888-040OtherSTATE PHARMACIST LICENSE