Provider Demographics
NPI:1336750322
Name:MARTIN, MYREEN (RPH)
Entity Type:Individual
Prefix:
First Name:MYREEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5913
Mailing Address - Country:US
Mailing Address - Phone:201-558-0094
Mailing Address - Fax:
Practice Address - Street 1:3333 PARK AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5913
Practice Address - Country:US
Practice Address - Phone:201-558-0094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03756800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8628807Medicaid