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General NPI Number Information
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NPI Number | 1881000594
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Entity Type | Individual
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Provider Name | JENNA B MATSO
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Gender | Female
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Dates
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Enumeration Date | 07/02/2014
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Last Update Date | 07/02/2014
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Provider Practice Location Address
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Address Line | 4580 LIBERTY AVE
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City | VERMILION
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State | OH
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Zip | 44089-3285
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Country | US
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Telephone | 440-967-2018
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Fax |
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Provider Business Mailing Address
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Address Line | 1917 ATLANTIC AVE
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City | SANDUSKY
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State | OH
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Zip | 44870-7041
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Country | US
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Telephone | 419-202-7649
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 03234041
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License Number State | OH
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