Provider Demographics
NPI:1063012615
Name:MARTIN, WILLIAM JOHN JR
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:MARTIN
Suffix:JR
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 1:307 W STROUD ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7123
Mailing Address - Country:US
Mailing Address - Phone:501-209-0030
Mailing Address - Fax:
Practice Address - Street 1:1600 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-9401
Practice Address - Country:US
Practice Address - Phone:870-886-6605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCO8286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty