Healthcare Provider Details

I. General information

NPI: 1114138203
Provider Name (Legal Business Name): SHERI MATTESON ST. CLAIR R. PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 OAKLAND DR KCMS PHARMACY
KALAMAZOO MI
49008-1282
US

IV. Provider business mailing address

4515 HIDDEN SHORE DR
KALAMAZOO MI
49048-8253
US

V. Phone/Fax

Practice location:
  • Phone: 269-337-6330
  • Fax:
Mailing address:
  • Phone: 269-342-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302025805
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: