Provider Demographics
NPI:1285855338
Name:DANIEL, MARTY (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARTY
Middle Name:
Last Name:DANIEL
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 1:3520 KNICKERBOCKER ROAD SUITE A
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904
Mailing Address - Country:US
Mailing Address - Phone:325-949-4577
Mailing Address - Fax:325-224-0997
Practice Address - Street 1:3520 KNICKERBOCKER ROAD SUITE A
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-949-4577
Practice Address - Fax:325-224-0997
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist