Healthcare Provider Details

I. General information

NPI: 1245722545
Provider Name (Legal Business Name): MATHEW ANTHONY LETIZIA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E NORTH AVE
MILWAUKEE WI
53212-3515
US

IV. Provider business mailing address

8531 W HAYES PL
WEST ALLIS WI
53227-2536
US

V. Phone/Fax

Practice location:
  • Phone: 414-588-2865
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number1875440
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: