Provider Demographics
NPI:1093170334
Name:MARTIN, RICHARD DEWAYNE (RPH, CDE)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DEWAYNE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RPH, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 NW JOHN JONES
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028
Mailing Address - Country:US
Mailing Address - Phone:817-447-3213
Mailing Address - Fax:
Practice Address - Street 1:165 NW JOHN JONES DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5154
Practice Address - Country:US
Practice Address - Phone:817-447-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist