MEDICARE: MR. GERARDO MARTIN RPH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	9397	SC

General Provider Information

NPI Number	:	1083032999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GERARDO MARTIN RPH.

Provider Business Mailing Address
First Line	:	175 HIGHWAY 274
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-6045
Country	:	US
Telephone Number	:	803-619-7028
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 HIGHWAY 274
Second Line	:
City	:	LAKE WYLIE
State	:	SC
Zip	:	29710-6045
Country	:	US
Telephone Number	:	803-619-7028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2014
Last Update Date	:	03/29/2014

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