Provider Demographics
NPI:1063004026
Name:MARTIN, BRIAN JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOHN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FLUCOM MDWS
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-3517
Mailing Address - Country:US
Mailing Address - Phone:314-276-2242
Mailing Address - Fax:
Practice Address - Street 1:10666 BUSINESS 21
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-5097
Practice Address - Country:US
Practice Address - Phone:636-797-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist