Provider Demographics
NPI:1013586221
Name:MARTIN, JED
Entity Type:Individual
Prefix:
First Name:JED
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 1:2413 CRAWFORD RD
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-3648
Mailing Address - Country:US
Mailing Address - Phone:334-298-2577
Mailing Address - Fax:
Practice Address - Street 1:510 MAIN ST
Practice Address - Street 2:
Practice Address - City:HURTSBORO
Practice Address - State:AL
Practice Address - Zip Code:36860
Practice Address - Country:US
Practice Address - Phone:334-703-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist