Healthcare Provider Details

I. General information

NPI: 1982984456
Provider Name (Legal Business Name): DAVID ELLERY MATHIS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2011
Last Update Date: 08/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 W US HIGHWAY 90
LAKE CITY FL
32055-4720
US

IV. Provider business mailing address

2094 W US HIGHWAY 90
LAKE CITY FL
32055-4720
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-0313
  • Fax: 386-755-5994
Mailing address:
  • Phone: 386-755-0313
  • Fax: 386-755-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS41750
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: