Provider Demographics
NPI:1518093103
Name:MATHIS, RAYMOND DOUGLAS (DPH)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:DOUGLAS
Last Name:MATHIS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104A W UNIVERSITY PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1635
Mailing Address - Country:US
Mailing Address - Phone:731-661-0333
Mailing Address - Fax:731-661-0343
Practice Address - Street 1:104A W UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1635
Practice Address - Country:US
Practice Address - Phone:731-661-0333
Practice Address - Fax:731-661-0343
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist