Provider Demographics
NPI:1396378097
Name:MARTIN, KATHLEEN ROSE (DPH)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ROSE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14101 N DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:JONES
Mailing Address - State:OK
Mailing Address - Zip Code:73049-3455
Mailing Address - Country:US
Mailing Address - Phone:405-659-6780
Mailing Address - Fax:405-390-4745
Practice Address - Street 1:14185 MACK HARRINGTON DR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-2035
Practice Address - Country:US
Practice Address - Phone:405-390-4495
Practice Address - Fax:405-390-4745
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist