Provider Demographics
NPI:1710328893
Name:MATHIS, ALAN RYAN
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:RYAN
Last Name:MATHIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 VILLAGE CENTER DR
Mailing Address - Street 2:UNIT #301
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-2853
Mailing Address - Country:US
Mailing Address - Phone:863-397-5696
Mailing Address - Fax:
Practice Address - Street 1:5375 N SOCRUM LOOP RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4272
Practice Address - Country:US
Practice Address - Phone:863-859-6353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist