Provider Demographics
NPI:1104079375
Name:MATTINGLY, WILLILAM PATRICK (RPH)
Entity type:Individual
Prefix:MR
First Name:WILLILAM
Middle Name:PATRICK
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1362
Mailing Address - Country:US
Mailing Address - Phone:270-692-4950
Mailing Address - Fax:270-692-2320
Practice Address - Street 1:498 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1362
Practice Address - Country:US
Practice Address - Phone:270-692-4950
Practice Address - Fax:270-692-2320
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist