Provider Demographics
NPI:1609274711
Name:MARTIN, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MARTIN
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 1:4100 US HIGHWAY 41A
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-9369
Mailing Address - Country:US
Mailing Address - Phone:270-827-9729
Mailing Address - Fax:
Practice Address - Street 1:408 N MORGAN ST
Practice Address - Street 2:
Practice Address - City:MORGANFIELD
Practice Address - State:KY
Practice Address - Zip Code:42437-1240
Practice Address - Country:US
Practice Address - Phone:270-389-4556
Practice Address - Fax:270-389-9496
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017354183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist