Provider Demographics
NPI:1902303977
Name:MACZIEWSKI, MATHEW WILLIAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:WILLIAM
Last Name:MACZIEWSKI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CORNHUSKER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-3924
Mailing Address - Country:US
Mailing Address - Phone:402-494-8850
Mailing Address - Fax:
Practice Address - Street 1:1601 CORNHUSKER DR
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3924
Practice Address - Country:US
Practice Address - Phone:402-494-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21248183500000X
NE13448183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE13448OtherPHARMACIST
IA21248OtherPHARMACIST