Provider Demographics
NPI:1083004337
Name:MATHENY, TIFFANY LYNNE
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:LYNNE
Last Name:MATHENY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MARKETSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0574
Mailing Address - Country:US
Mailing Address - Phone:904-825-1913
Mailing Address - Fax:
Practice Address - Street 1:120 MARKETSIDE AVE
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0574
Practice Address - Country:US
Practice Address - Phone:904-825-1913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52310183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist