Provider Demographics
NPI:1558062703
Name:PADILLA, MARTHA M
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
Last Name:PADILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SNOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363-8763
Mailing Address - Country:US
Mailing Address - Phone:510-612-3223
Mailing Address - Fax:
Practice Address - Street 1:1050 N WILSON WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4218
Practice Address - Country:US
Practice Address - Phone:209-948-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38645183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician