=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972191120
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE MICHELLE MARTINEZ PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2021
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 JACAMAN RD
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-6194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-722-7600
-----------------------------------------------------
Fax | 956-722-7619
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2403 WILLIAMS CT
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78045-8158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-324-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 60866
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------