Provider Demographics
NPI:1467085274
Name:MARTIN, KENNETH (RPH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:100 GREENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2106
Mailing Address - Country:US
Mailing Address - Phone:601-540-2121
Mailing Address - Fax:
Practice Address - Street 1:1811 WEST GOVT ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2106
Practice Address - Country:US
Practice Address - Phone:601-828-3773
Practice Address - Fax:
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
MSE-70981835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE-7098OtherMS BOARD OF PHARMACY