Provider Demographics
NPI:1598582082
Name:MATTERN, JOHN CLIFTON (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CLIFTON
Last Name:MATTERN
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:W10426 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-8800
Mailing Address - Country:US
Mailing Address - Phone:608-235-1259
Mailing Address - Fax:
Practice Address - Street 1:2700 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9221
Practice Address - Country:US
Practice Address - Phone:608-742-5727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist