Provider Demographics
NPI:1639571854
Name:MATHIS, GRANT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:MATHIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9058
Mailing Address - Country:US
Mailing Address - Phone:270-443-0909
Mailing Address - Fax:
Practice Address - Street 1:2755 W PARK DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9058
Practice Address - Country:US
Practice Address - Phone:270-443-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017392183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist