Provider Demographics
NPI:1932482015
Name:MATTERN, VIRGINIA
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:
Last Name:MATTERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 GRANDVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:61548-9139
Mailing Address - Country:US
Mailing Address - Phone:309-383-2547
Mailing Address - Fax:
Practice Address - Street 1:1200 E WAR MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-7723
Practice Address - Country:US
Practice Address - Phone:309-682-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051038152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist