Healthcare Provider Details

I. General information

NPI: 1275168791
Provider Name (Legal Business Name): MATTHEW MAZUR PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 MAIN ST
GREEN BAY WI
54302-3918
US

IV. Provider business mailing address

1819 MAIN ST
GREEN BAY WI
54302-3918
US

V. Phone/Fax

Practice location:
  • Phone: 920-469-3436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number18360-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: