Provider Demographics
NPI:1881117786
Name:MATHIAS, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MATHIAS
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 1:10151 FAIRFIELD FARMS DR
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-7907
Mailing Address - Country:US
Mailing Address - Phone:614-975-5976
Mailing Address - Fax:
Practice Address - Street 1:1141 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-4056
Practice Address - Country:US
Practice Address - Phone:740-653-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
361889OtherNABP