Provider Demographics
NPI:1750981957
Name:MATHEWS, MARK (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MATHEWS
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 1:124 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:TX
Mailing Address - Zip Code:76365-2804
Mailing Address - Country:US
Mailing Address - Phone:940-538-4361
Mailing Address - Fax:
Practice Address - Street 1:124 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:TX
Practice Address - Zip Code:76365-2804
Practice Address - Country:US
Practice Address - Phone:940-538-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist