Healthcare Provider Details

I. General information

NPI: 1902181118
Provider Name (Legal Business Name): MATTHEW JACOB GUMM PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MAIN ST
WAUNAKEE WI
53597-1101
US

IV. Provider business mailing address

401 W MAIN ST
WAUNAKEE WI
53597-1101
US

V. Phone/Fax

Practice location:
  • Phone: 608-850-6203
  • Fax: 608-850-6207
Mailing address:
  • Phone: 608-850-6203
  • Fax: 608-850-6207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14717-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: