Provider Demographics
NPI:1306356092
Name:MARTNICKS PHARMACY & MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:MARTNICKS PHARMACY & MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:ONYENWE
Authorized Official - Suffix:
Authorized Official - Credentials:RPHD
Authorized Official - Phone:954-530-4698
Mailing Address - Street 1:1107 E HALLANDALE BEACH BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4431
Mailing Address - Country:US
Mailing Address - Phone:954-530-3024
Mailing Address - Fax:954-530-4285
Practice Address - Street 1:1107 E HALLANDALE BEACH BLVD STE B
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4431
Practice Address - Country:US
Practice Address - Phone:954-530-3024
Practice Address - Fax:954-530-4285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-06
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL254523336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004851500Medicaid