Healthcare Provider Details

I. General information

NPI: 1174249296
Provider Name (Legal Business Name): STEPHANIE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 EAST 7TH STREET
ATLANTIC IA
50022
US

IV. Provider business mailing address

1607 EAST 7TH STREET
ATLANTIC IA
50022
US

V. Phone/Fax

Practice location:
  • Phone: 712-243-2110
  • Fax: 712-243-2209
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24568
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: