Provider Demographics
NPI:1407158629
Name:PRINCE, MARTEZ LAVARD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARTEZ
Middle Name:LAVARD
Last Name:PRINCE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 MONROE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7533
Mailing Address - Country:US
Mailing Address - Phone:704-496-9182
Mailing Address - Fax:704-496-9903
Practice Address - Street 1:3010 MONROE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7532
Practice Address - Country:US
Practice Address - Phone:704-496-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7539430001Medicare NSC