Healthcare Provider Details

I. General information

NPI: 1871887380
Provider Name (Legal Business Name): TODD JOSEPH MATTINGLY II PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5614 HARRODS CV
PROSPECT KY
40059-9350
US

IV. Provider business mailing address

5614 HARRODS CV
PROSPECT KY
40059-9350
US

V. Phone/Fax

Practice location:
  • Phone: 502-552-5104
  • Fax:
Mailing address:
  • Phone: 502-552-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number014493
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: