Provider Demographics
NPI:1659826006
Name:MARTENS, BRYCE
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:MARTENS
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 1:7804 E FUNSTON ST
Mailing Address - Street 2:STE 204
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-3107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7804 E FUNSTON ST
Practice Address - Street 2:STE 204
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-3107
Practice Address - Country:US
Practice Address - Phone:316-821-9649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-14928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist