Provider Demographics
NPI:1295136810
Name:MATHES, TIMOTHY JAMES
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:MATHES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:HARPER
Mailing Address - State:KS
Mailing Address - Zip Code:67058-1432
Mailing Address - Country:US
Mailing Address - Phone:620-896-7879
Mailing Address - Fax:
Practice Address - Street 1:1111 W 8TH ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-3424
Practice Address - Country:US
Practice Address - Phone:620-326-5981
Practice Address - Fax:620-326-4106
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35505183500000X
KS12436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist