Provider Demographics
NPI:1205109170
Name:MARTIN, LYNETTE (RPH)
Entity type:Individual
Prefix:MS
First Name:LYNETTE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:LYN
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:8601 CHAMBERS PL, NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8601 CHAMBERS PL, NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2033
Practice Address - Country:US
Practice Address - Phone:505-823-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRPH00006074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist