Provider Demographics
NPI:1336818798
Name:MARTINS, LARISSA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:MARTINS
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 1:4740 CYPRESS GARDENS LOOP UNIT 9102
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-7064
Mailing Address - Country:US
Mailing Address - Phone:239-896-5174
Mailing Address - Fax:
Practice Address - Street 1:11851 PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-5912
Practice Address - Country:US
Practice Address - Phone:239-896-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL63183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist