Provider Demographics
NPI:1528344488
Name:PROEBSTLE, MATTHEW HAROLD (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:HAROLD
Last Name:PROEBSTLE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 STATE ROAD 82
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1402
Mailing Address - Country:US
Mailing Address - Phone:608-847-7814
Mailing Address - Fax:
Practice Address - Street 1:403 STATE ROAD 82
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1402
Practice Address - Country:US
Practice Address - Phone:608-847-7814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15049-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist