Provider Demographics
NPI:1083210181
Name:DAVENPORT, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:DAVENPORT
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 1:358 WATERWAY TRL
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:KY
Mailing Address - Zip Code:42076-4826
Mailing Address - Country:US
Mailing Address - Phone:270-227-2911
Mailing Address - Fax:
Practice Address - Street 1:100 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1912
Practice Address - Country:US
Practice Address - Phone:270-753-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY010140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist