Provider Demographics
NPI:1073627212
Name:MARTIN, DELBERT GARY (RPH)
Entity Type:Individual
Prefix:MR
First Name:DELBERT
Middle Name:GARY
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 1:6822 EAST 1000 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FORT DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84026
Mailing Address - Country:US
Mailing Address - Phone:435-725-6874
Mailing Address - Fax:
Practice Address - Street 1:6822 EAST 1000 SOUTH
Practice Address - Street 2:
Practice Address - City:FORT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-725-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT341687-17011835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT700000000009Medicaid
UT700000000009Medicaid
UTHSZ216Medicare PIN