Provider Demographics
NPI:1982984456
Name:MATHIS, DAVID ELLERY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ELLERY
Last Name:MATHIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2094 W US HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4720
Mailing Address - Country:US
Mailing Address - Phone:386-755-0313
Mailing Address - Fax:386-755-5994
Practice Address - Street 1:2094 W US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4720
Practice Address - Country:US
Practice Address - Phone:386-755-0313
Practice Address - Fax:386-755-5994
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-28
Last Update Date:2011-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPS41750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist