Provider Demographics
NPI:1649497587
Name:MARTIN, NICHOLAS JAMES (PHARM D)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JAMES
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CONIFEROUS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-7960
Mailing Address - Country:US
Mailing Address - Phone:314-435-7344
Mailing Address - Fax:
Practice Address - Street 1:3865 GRAVOIS AVE
Practice Address - Street 2:PHARMACY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4657
Practice Address - Country:US
Practice Address - Phone:314-771-0218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006024033183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist