Provider Demographics
NPI:1982097952
Name:MATHIS, JERRY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MATHIS
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:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:DANDRIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37725-0332
Mailing Address - Country:US
Mailing Address - Phone:865-484-0263
Mailing Address - Fax:865-484-0769
Practice Address - Street 1:123 W HIGHWAY 25 70
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-6401
Practice Address - Country:US
Practice Address - Phone:865-484-0263
Practice Address - Fax:865-424-0769
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10422183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist