Provider Demographics
NPI:1942581442
Name:MARTIN, JOHN BROOKE (DPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BROOKE
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 1:1111 N COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-3922
Mailing Address - Country:US
Mailing Address - Phone:580-226-6978
Mailing Address - Fax:
Practice Address - Street 1:1111 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-3922
Practice Address - Country:US
Practice Address - Phone:580-226-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist