MEDICARE: DR. ALAN RYAN MATHIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS50590	FL

General Provider Information

NPI Number	:	1710328893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALAN RYAN MATHIS

Provider Business Mailing Address
First Line	:	1530 VILLAGE CENTER DR
Second Line	:	UNIT #301
City	:	LAKELAND
State	:	FL
Zip	:	33803-2853
Country	:	US
Telephone Number	:	863-397-5696
Fax Number	:

Provider Business Practice Location Address
First Line	:	5375 N SOCRUM LOOP RD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33809-4272
Country	:	US
Telephone Number	:	863-859-6353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2013
Last Update Date	:	07/17/2013

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