Healthcare Provider Details

I. General information

NPI: 1336519032
Provider Name (Legal Business Name): ANDREW MARTIN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 MISSOURI AVE
CARTHAGE MO
64836-3060
US

IV. Provider business mailing address

1601 MISSOURI AVE
CARTHAGE MO
64836-3060
US

V. Phone/Fax

Practice location:
  • Phone: 417-359-8185
  • Fax: 417-359-8276
Mailing address:
  • Phone: 417-359-8185
  • Fax: 417-359-8276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2004031550
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR-13567
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: