Provider Demographics
NPI:1972264117
Name:MATTINGLY, THOMAS LEE (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
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 1:630 N CAROL MALONE BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1124
Mailing Address - Country:US
Mailing Address - Phone:606-475-0033
Mailing Address - Fax:
Practice Address - Street 1:630 N CAROL MALONE BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1124
Practice Address - Country:US
Practice Address - Phone:606-475-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-09
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY83613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8361OtherKENTUCKY BOARD OF PHARMACY