Provider Demographics
NPI:1063820405
Name:MATTSON, JACK (RPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MATTSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2222
Mailing Address - Country:US
Mailing Address - Phone:316-691-9134
Mailing Address - Fax:316-691-9138
Practice Address - Street 1:3707 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2222
Practice Address - Country:US
Practice Address - Phone:316-691-9134
Practice Address - Fax:316-691-9138
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist