Provider Demographics
NPI:1841537644
Name:MATHESON, MARK DANIEL (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:MATHESON
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 1:2061 EXPERIMENT STATION RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-5328
Mailing Address - Country:US
Mailing Address - Phone:706-769-2086
Mailing Address - Fax:706-769-7653
Practice Address - Street 1:2061 EXPERIMENT STATION RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-5328
Practice Address - Country:US
Practice Address - Phone:706-769-2086
Practice Address - Fax:706-769-7653
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019230183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist