Provider Demographics
NPI:1396336905
Name:THILL, MATTHEW CHARLES
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHARLES
Last Name:THILL
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:N2781 WILDERNESS TR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143
Mailing Address - Country:US
Mailing Address - Phone:715-923-6288
Mailing Address - Fax:
Practice Address - Street 1:1015 13TH ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-2722
Practice Address - Country:US
Practice Address - Phone:906-863-2589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist