Healthcare Provider Details

I. General information

NPI: 1699630244
Provider Name (Legal Business Name): ANN MATHEW PADIKKAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6119 AUDUBON MANOR BLVD
LITHIA FL
33547-5032
US

IV. Provider business mailing address

6119 AUDUBON MANOR BLVD
LITHIA FL
33547-5032
US

V. Phone/Fax

Practice location:
  • Phone: 217-979-9898
  • Fax:
Mailing address:
  • Phone: 217-979-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS47749
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: