Provider Demographics
NPI:1124781307
Name:MATHIS, SAMUEL AUSTIN (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:AUSTIN
Last Name:MATHIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 WAGONTREE CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-7758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 E DIXON BLVD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152-6765
Practice Address - Country:US
Practice Address - Phone:704-481-8557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist