Provider Demographics
NPI:1104540277
Name:MATHEWS, JAY THOMAS
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:THOMAS
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2713
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77305-2713
Mailing Address - Country:US
Mailing Address - Phone:847-293-8399
Mailing Address - Fax:
Practice Address - Street 1:910 W DAVIS ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-2709
Practice Address - Country:US
Practice Address - Phone:936-539-1849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12890-40183500000X
IL051.039862183500000X
TX56465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist