Provider Demographics
NPI:1215591672
Name:REISKY, MARTY (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARTY
Middle Name:
Last Name:REISKY
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 1:1407 57TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-3646
Mailing Address - Country:US
Mailing Address - Phone:941-727-9120
Mailing Address - Fax:941-727-9122
Practice Address - Street 1:1407 57TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3646
Practice Address - Country:US
Practice Address - Phone:941-727-9120
Practice Address - Fax:941-727-9122
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist