Healthcare Provider Details

I. General information

NPI: 1851810220
Provider Name (Legal Business Name): DAVID MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2017
Last Update Date: 09/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2B STATE ROAD 344
EDGEWOOD NM
87015-6951
US

IV. Provider business mailing address

9 VISTA VERDE WAY
EDGEWOOD NM
87015-8725
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-9040
  • Fax:
Mailing address:
  • Phone: 505-204-6143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00008812
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: