Provider Demographics
NPI:1275135121
Name:MARTINDALE, WARREN GREGORY
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:GREGORY
Last Name:MARTINDALE
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 1:133 ARKANSAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1963
Mailing Address - Country:US
Mailing Address - Phone:870-772-7874
Mailing Address - Fax:870-772-7874
Practice Address - Street 1:133 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1963
Practice Address - Country:US
Practice Address - Phone:870-772-7874
Practice Address - Fax:870-772-7874
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist