Provider Demographics
NPI:1013682343
Name:MATTISON, ALYSSA MONIQUE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MONIQUE
Last Name:MATTISON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 OAK BAY DR
Mailing Address - Street 2:
Mailing Address - City:OSPREY
Mailing Address - State:FL
Mailing Address - Zip Code:34229-8958
Mailing Address - Country:US
Mailing Address - Phone:315-751-1644
Mailing Address - Fax:
Practice Address - Street 1:3500 N TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-5358
Practice Address - Country:US
Practice Address - Phone:941-444-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62892.183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist