Provider Demographics
NPI:1710464144
Name:MARTINEZ, MEGAN RAE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:RAE
Last Name:MARTINEZ
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 1:412 S PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-3254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 MILLS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4671
Practice Address - Country:US
Practice Address - Phone:505-425-3317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008933183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist