Provider Demographics
NPI:1659794634
Name:MARTIN, MEGAN LANE (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:MEGAN
Middle Name:LANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LANE
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 E TONTO ST
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-1145
Mailing Address - Country:US
Mailing Address - Phone:731-571-8233
Mailing Address - Fax:928-475-2653
Practice Address - Street 1:100 N BROAD ST
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-2502
Practice Address - Country:US
Practice Address - Phone:928-425-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist