Provider Demographics
NPI:1417560046
Name:MARTIN, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-3403
Mailing Address - Country:US
Mailing Address - Phone:229-758-3168
Mailing Address - Fax:229-758-8354
Practice Address - Street 1:211 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COLQUITT
Practice Address - State:GA
Practice Address - Zip Code:39837-3403
Practice Address - Country:US
Practice Address - Phone:229-758-3168
Practice Address - Fax:229-758-8354
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist