Provider Demographics
NPI:1578122065
Name:MARTIN, KENNETH KEVIN
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:KEVIN
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 1:700 SCOTT AND WHITE DR # 1.112
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6441
Mailing Address - Country:US
Mailing Address - Phone:979-207-0120
Mailing Address - Fax:979-207-0128
Practice Address - Street 1:700 SCOTT AND WHITE DR # 1.112
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6441
Practice Address - Country:US
Practice Address - Phone:979-207-0120
Practice Address - Fax:979-207-0128
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist