Provider Demographics
NPI:1952698052
Name:MARTIN, BRYAN EVAN (RPH)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:EVAN
Last Name:MARTIN
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 1:836 SHIFLETT RD
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-7378
Mailing Address - Country:US
Mailing Address - Phone:229-896-4772
Mailing Address - Fax:229-896-1621
Practice Address - Street 1:714 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-2656
Practice Address - Country:US
Practice Address - Phone:229-896-1601
Practice Address - Fax:229-896-1621
Is Sole Proprietor?:No
Enumeration Date:2011-07-09
Last Update Date:2011-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH019619OtherGA LICENSE