Healthcare Provider Details

I. General information

NPI: 1346305554
Provider Name (Legal Business Name): MARTIN MEMORIAL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HOSPITAL AVE
STUART FL
34994-2346
US

IV. Provider business mailing address

200 HOSPITAL AVE PO BOX 9010
STUART FL
34995-2396
US

V. Phone/Fax

Practice location:
  • Phone: 772-288-5813
  • Fax: 772-221-2064
Mailing address:
  • Phone: 772-834-4980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH9554
License Number StateFL

VIII. Authorized Official

Name: TIMOTHY L. LONGVILLE
Title or Position: CHIEF ACCOUNTING OFFICER/CONTROLLER
Credential:
Phone: 216-636-7416