Healthcare Provider Details

I. General information

NPI: 1376957639
Provider Name (Legal Business Name): R & L MARTIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W EDMOND RD
EDMOND OK
73003-5602
US

IV. Provider business mailing address

410 W EDMOND RD
EDMOND OK
73003-5602
US

V. Phone/Fax

Practice location:
  • Phone: 405-341-1504
  • Fax: 405-341-1506
Mailing address:
  • Phone: 405-341-1504
  • Fax: 405-341-1506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1-6725
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RANDY MARTIN
Title or Position: MANAGING MEMBER
Credential:
Phone: 405-341-1504