Provider Demographics
NPI:1538566195
Name:MATHEWS, ANITHA (RPH)
Entity type:Individual
Prefix:
First Name:ANITHA
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6213 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7278
Mailing Address - Country:US
Mailing Address - Phone:262-358-2310
Mailing Address - Fax:
Practice Address - Street 1:2811 18TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4665
Practice Address - Country:US
Practice Address - Phone:262-551-0367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15297-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist