Provider Demographics
NPI:1356468714
Name:MARTIN, BRIAN L (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:MARTIN
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 1:1578 MUD SWITCH ROAD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45146
Mailing Address - Country:US
Mailing Address - Phone:937-302-7413
Mailing Address - Fax:
Practice Address - Street 1:601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BLANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45107-1141
Practice Address - Country:US
Practice Address - Phone:937-783-3999
Practice Address - Fax:937-783-3995
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-25201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist