Provider Demographics
NPI:1275138182
Name:MATTINGLY, MARISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MATTINGLY
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 1:9103 SARGENT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1131
Mailing Address - Country:US
Mailing Address - Phone:317-698-9655
Mailing Address - Fax:
Practice Address - Street 1:1421 S RANGELINE RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2933
Practice Address - Country:US
Practice Address - Phone:317-844-2775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026680A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist