Provider Demographics
NPI:1730566316
Name:MATTHYS, KEN (PHARMD)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:MATTHYS
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 1:376 SOUTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 E EAU GALLIE BLVD
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4874
Practice Address - Country:US
Practice Address - Phone:321-773-2977
Practice Address - Fax:321-773-7494
Is Sole Proprietor?:No
Enumeration Date:2015-05-02
Last Update Date:2015-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist