Provider Demographics
NPI:1528604642
Name:MATHIEU, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:MATHIEU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1005
Mailing Address - Country:US
Mailing Address - Phone:815-434-1395
Mailing Address - Fax:815-434-1396
Practice Address - Street 1:2701 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1005
Practice Address - Country:US
Practice Address - Phone:815-434-1395
Practice Address - Fax:815-434-1396
Is Sole Proprietor?:No
Enumeration Date:2019-11-24
Last Update Date:2019-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL311569568704Medicaid