Provider Demographics
NPI:1245433119
Name:MATHISON, STEPHEN E (REGPH)
Entity Type:Individual
Prefix:MISS
First Name:STEPHEN
Middle Name:E
Last Name:MATHISON
Suffix:
Gender:M
Credentials:REGPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2635
Mailing Address - Country:US
Mailing Address - Phone:406-752-8059
Mailing Address - Fax:
Practice Address - Street 1:900 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3844
Practice Address - Country:US
Practice Address - Phone:406-257-7564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist