Provider Demographics
NPI:1598010449
Name:MARTIN, DAVID ELLIS (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ELLIS
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 1:1705 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-1873
Mailing Address - Country:US
Mailing Address - Phone:575-623-9001
Mailing Address - Fax:575-625-0428
Practice Address - Street 1:1705 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-1873
Practice Address - Country:US
Practice Address - Phone:575-623-9001
Practice Address - Fax:575-625-0428
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00004065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist