Provider Demographics
NPI:1124676937
Name:KOEBEL, MATHEW RICHARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:RICHARD
Last Name:KOEBEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N BERNHARDT AVE
Mailing Address - Street 2:
Mailing Address - City:GERALD
Mailing Address - State:MO
Mailing Address - Zip Code:63037-1625
Mailing Address - Country:US
Mailing Address - Phone:314-640-0225
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-348-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019030620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist