Basic Information
| Provider Information | |||||||||
| NPI: | 1104540277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHEWS | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2713 | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773052713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472938399 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 910 W DAVIS ST | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773012709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365391849 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2022 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 12890-40 | WI | N | Pharmacy Service Providers | Pharmacist | 183500000X | 051.039862 | IL | N | Pharmacy Service Providers | Pharmacist | 183500000X | 56465 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.