Provider Demographics
NPI:1912283698
Name:ENGLERTH, MATTHEW J
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:J
Last Name:ENGLERTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2335
Mailing Address - Country:US
Mailing Address - Phone:608-269-4031
Mailing Address - Fax:608-269-4062
Practice Address - Street 1:710 W WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2335
Practice Address - Country:US
Practice Address - Phone:608-269-4031
Practice Address - Fax:608-269-4062
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12314-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist