Provider Demographics
NPI:1225387525
Name:MARTIN, SPANTAMMIE D
Entity Type:Individual
Prefix:MRS
First Name:SPANTAMMIE
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
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 236
Mailing Address - Street 2:
Mailing Address - City:IVA
Mailing Address - State:SC
Mailing Address - Zip Code:29655-0236
Mailing Address - Country:US
Mailing Address - Phone:864-844-1659
Mailing Address - Fax:
Practice Address - Street 1:4405 HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29626-5216
Practice Address - Country:US
Practice Address - Phone:864-226-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist