Provider Demographics
NPI:1407155294
Name:MARTIN, GREGORY WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WAYNE
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 1:2300 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1347
Mailing Address - Country:US
Mailing Address - Phone:304-295-4573
Mailing Address - Fax:304-295-0639
Practice Address - Street 1:2300 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1347
Practice Address - Country:US
Practice Address - Phone:304-295-4573
Practice Address - Fax:304-295-0639
Is Sole Proprietor?:No
Enumeration Date:2011-03-20
Last Update Date:2011-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist