Provider Demographics
NPI:1568012201
Name:MARTIN, NATHAN RAY
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:RAY
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 1:1034 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEAN STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37708-4257
Mailing Address - Country:US
Mailing Address - Phone:865-993-4074
Mailing Address - Fax:
Practice Address - Street 1:1034 MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAN STATION
Practice Address - State:TN
Practice Address - Zip Code:37708-4257
Practice Address - Country:US
Practice Address - Phone:865-993-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist