Provider Demographics
NPI:1487024287
Name:MATHIS, LAURA (PHARM D)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KENWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-1939
Mailing Address - Country:US
Mailing Address - Phone:620-365-1612
Mailing Address - Fax:
Practice Address - Street 1:2700 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-3204
Practice Address - Country:US
Practice Address - Phone:620-431-4064
Practice Address - Fax:620-431-6055
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-13780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist