Provider Demographics
NPI:1821296138
Name:MARTIN, PATTY
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:MARTIN
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 1:201 SUMMERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-3277
Mailing Address - Country:US
Mailing Address - Phone:501-653-2890
Mailing Address - Fax:
Practice Address - Street 1:100 RIVENDELL DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-9188
Practice Address - Country:US
Practice Address - Phone:501-316-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist