Provider Demographics
NPI:1457416802
Name:ROBERTSON, MARTIN CLIFTON
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:CLIFTON
Last Name:ROBERTSON
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 1:1201 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-2746
Mailing Address - Country:US
Mailing Address - Phone:870-774-3666
Mailing Address - Fax:870-772-8062
Practice Address - Street 1:1201 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2746
Practice Address - Country:US
Practice Address - Phone:870-774-3666
Practice Address - Fax:870-772-8062
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR05524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0377960001Medicare NSC