Provider Demographics
NPI:1265602130
Name:GANAN, MARTIN A (RPH)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:A
Last Name:GANAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W STATE ST
Mailing Address - Street 2:PHARMACY.
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1633
Mailing Address - Fax:815-963-4629
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:PHARMACY
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102
Practice Address - Country:US
Practice Address - Phone:815-490-1633
Practice Address - Fax:815-963-4629
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist