Provider Demographics
NPI:1093095507
Name:MARTIN, JACQUELYN KEENAN (RPH)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:KEENAN
Last Name:MARTIN
Suffix:
Gender:F
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:PO BOX 11780
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24062-1780
Mailing Address - Country:US
Mailing Address - Phone:704-661-7051
Mailing Address - Fax:
Practice Address - Street 1:1477 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3120
Practice Address - Country:US
Practice Address - Phone:540-389-7251
Practice Address - Fax:540-387-1876
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206150183500000X
SC006153183500000X
NC10804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist