MEDICARE: MELISSA MARTIN

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	11263	OK

General Provider Information

NPI Number	:	1760086011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA MARTIN

Provider Business Mailing Address
First Line	:	12901 ELROND DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-2082
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 SW 104TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-3009
Country	:	US
Telephone Number	:	405-692-3866
Fax Number	:

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

Provider Enumeration Date	:	11/27/2020
Last Update Date	:	11/27/2020

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Directions to “ MELISSA MARTIN ” Practice Location

Language	Start Address	Practice Location

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