Provider Demographics
NPI:1508311028
Name:MATHEW, KOSHY (PHARMD, MBA, DAAPM)
Entity Type:Individual
Prefix:DR
First Name:KOSHY
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:PHARMD, MBA, DAAPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 MCDILL CV
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6562
Mailing Address - Country:US
Mailing Address - Phone:224-805-0156
Mailing Address - Fax:601-988-1701
Practice Address - Street 1:122 MCDILL CV
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6562
Practice Address - Country:US
Practice Address - Phone:224-805-0156
Practice Address - Fax:601-988-1701
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0510406061835P0018X
MSP133481835P0018X
KY0169491835P0018X
TN00000381121835P0018X
LAPST0205431835P0018X
ARPD126761835P0018X
OR00140781835P0018X
MD224061835P0018X
NE145331835P0018X
AZS0205511835P0018X
VA02022131811835P0018X
TX549651835P0018X
FLPS522421835P0018X
AL179981835P0018X
OK158511835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist