Provider Demographics
NPI:1265714513
Name:MAUTZ, JON MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:MICHAEL
Last Name:MAUTZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BLACKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-8032
Mailing Address - Country:US
Mailing Address - Phone:740-920-4308
Mailing Address - Fax:
Practice Address - Street 1:6320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2317
Practice Address - Country:US
Practice Address - Phone:614-759-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03225150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist