Provider Demographics
NPI:1003411398
Name:MARTIN, GEORGE
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 INDIAN CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033
Mailing Address - Country:US
Mailing Address - Phone:859-608-9051
Mailing Address - Fax:
Practice Address - Street 1:231 S 2ND ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1803
Practice Address - Country:US
Practice Address - Phone:859-236-2314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist