Provider Demographics
NPI:1710266853
Name:MARTIN, BOBBIE SHANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BOBBIE
Middle Name:SHANE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 AUTUMN DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OH
Mailing Address - Zip Code:45810-1830
Mailing Address - Country:US
Mailing Address - Phone:419-634-0776
Mailing Address - Fax:
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:CHILLICOTHE VA MEDICAL CENTER
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9718
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0322642021835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric