Provider Demographics
NPI:1073959748
Name:BECKER, MARTIN T (RPH)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:T
Last Name:BECKER
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 1:669 W PIERRE LN
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1531
Mailing Address - Country:US
Mailing Address - Phone:262-284-6127
Mailing Address - Fax:
Practice Address - Street 1:1011 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1207
Practice Address - Country:US
Practice Address - Phone:262-284-3436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8401-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist