Provider Demographics
NPI:1861418444
Name:MATHIS DRUG STORE, INC.
Entity type:Organization
Organization Name:MATHIS DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:620-724-4313
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:KS
Mailing Address - Zip Code:66743-0097
Mailing Address - Country:US
Mailing Address - Phone:620-724-8400
Mailing Address - Fax:620-724-6900
Practice Address - Street 1:400 W SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:KS
Practice Address - Zip Code:66743-1213
Practice Address - Country:US
Practice Address - Phone:620-724-4313
Practice Address - Fax:620-724-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
KS2063543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100435000AMedicaid