Provider Demographics
NPI:1790389328
Name:MATHIS, TIMOTHY A
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
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 1:603 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-2267
Mailing Address - Country:US
Mailing Address - Phone:309-231-9096
Mailing Address - Fax:
Practice Address - Street 1:603 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2267
Practice Address - Country:US
Practice Address - Phone:309-274-6261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.2881401835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy