MEDICARE: THOMAS MARTENS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	111577-4	MN

General Provider Information

NPI Number	:	1689617250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS MARTENS

Provider Business Mailing Address
First Line	:	6468 157TH ST W
Second Line	:
City	:	APPLE VALLEY
State	:	MN
Zip	:	55124-6008
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2128 FORD PKWY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1863
Country	:	US
Telephone Number	:	651-251-3491
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/08/2007

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