Provider Demographics
NPI:1346305554
Name:MARTIN MEMORIAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MARTIN MEMORIAL MEDICAL CENTER INC
Other - Org Name:MARTIN MEMORIAL MEDICAL CENTER OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER/CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONGVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-636-7416
Mailing Address - Street 1:200 HOSPITAL AVE
Mailing Address - Street 2:PO BOX 9010
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-2396
Mailing Address - Country:US
Mailing Address - Phone:772-834-4980
Mailing Address - Fax:
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:772-288-5813
Practice Address - Fax:772-221-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
FLPH95543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2009571OtherPK