Provider Demographics
NPI:1952684490
Name:MATHEW, BLESSIN
Entity Type:Individual
Prefix:
First Name:BLESSIN
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 N 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8009
Mailing Address - Country:US
Mailing Address - Phone:417-576-1994
Mailing Address - Fax:
Practice Address - Street 1:1930 W GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-4870
Practice Address - Country:US
Practice Address - Phone:417-863-6416
Practice Address - Fax:417-863-1286
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009004997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist