Provider Demographics
NPI:1689734097
Name:MARTIN, MARK R (DPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 COVEY LN
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74352-7307
Mailing Address - Country:US
Mailing Address - Phone:918-521-5756
Mailing Address - Fax:
Practice Address - Street 1:510 S ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-6411
Practice Address - Country:US
Practice Address - Phone:918-825-2225
Practice Address - Fax:918-825-0972
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist