Provider Demographics
NPI:1083603294
Name:MATHEWS, MICAH HALLECK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:HALLECK
Last Name:MATHEWS
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 1:106 BRADBURY CIR N
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-8158
Mailing Address - Country:US
Mailing Address - Phone:251-786-2653
Mailing Address - Fax:
Practice Address - Street 1:27520 HIGHWAY 98
Practice Address - Street 2:PHARMACY
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4812
Practice Address - Country:US
Practice Address - Phone:251-626-5863
Practice Address - Fax:251-626-5890
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14759183500000X
GARPH021637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist