Provider Demographics
NPI:1073242525
Name:MATHIS, KEELEY GREEN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:KEELEY
Middle Name:GREEN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 EASTERN BYP STE G01
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2423
Mailing Address - Country:US
Mailing Address - Phone:859-626-0076
Mailing Address - Fax:
Practice Address - Street 1:793 EASTERN BYP STE G01
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2423
Practice Address - Country:US
Practice Address - Phone:859-626-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist