Provider Demographics
NPI:1497288062
Name:MARTA, JEFFREY
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:MARTA
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 1:1 ORCHARD
Mailing Address - Street 2:STE 210
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8337
Mailing Address - Country:US
Mailing Address - Phone:800-873-3611
Mailing Address - Fax:
Practice Address - Street 1:1 ORCHARD
Practice Address - Street 2:STE 210
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8337
Practice Address - Country:US
Practice Address - Phone:800-873-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist