Healthcare Provider Details

I. General information

NPI: 1013678960
Provider Name (Legal Business Name): NATHAN MARTIN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 E FOOTHILL BLVD
SAN LUIS OBISPO CA
93405-1700
US

IV. Provider business mailing address

1361 E ROSEMONT LN
FRESNO CA
93730-3569
US

V. Phone/Fax

Practice location:
  • Phone: 805-543-5697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH85663
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: