Provider Demographics
NPI:1922732650
Name:MATHES, ANDREW (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MATHES
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 1:6928 N MOON DRUMMER WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4851
Mailing Address - Country:US
Mailing Address - Phone:208-871-8258
Mailing Address - Fax:
Practice Address - Street 1:451 DEINHARD LN
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4800
Practice Address - Country:US
Practice Address - Phone:208-634-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-09
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist