Provider Demographics
NPI:1942229679
Name:MATHIS, GLEN M (RPH)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:M
Last Name:MATHIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:400 W SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:KS
Mailing Address - Zip Code:66743-1213
Mailing Address - Country:US
Mailing Address - Phone:620-724-4313
Mailing Address - Fax:620-724-6900
Practice Address - Street 1:400 W SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:KS
Practice Address - Zip Code:66743-1213
Practice Address - Country:US
Practice Address - Phone:620-724-4313
Practice Address - Fax:620-724-6900
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS206354183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100435000AMedicaid