=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639201049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD J. MATHIS RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8560 ARGYLE FOREST BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32244-5997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-779-7700
-----------------------------------------------------
Fax | 904-777-3054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3006 BRIDLEWOOD LN
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-5753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-731-2439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 34011
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------