Provider Demographics
NPI:1417158544
Name:MATTINGLY, DAVID RAY (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RAY
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 TARTAN DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-4789
Mailing Address - Country:US
Mailing Address - Phone:270-826-3232
Mailing Address - Fax:
Practice Address - Street 1:1355 2ND ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-3357
Practice Address - Country:US
Practice Address - Phone:270-827-9857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY9093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist