Provider Demographics
NPI:1083217913
Name:MATHIES, KELLI LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:MATHIES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553-1926
Mailing Address - Country:US
Mailing Address - Phone:812-295-4600
Mailing Address - Fax:812-295-9820
Practice Address - Street 1:402 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-1926
Practice Address - Country:US
Practice Address - Phone:812-295-4600
Practice Address - Fax:812-295-9820
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022480A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist