1669817904 NPI number — DR. EMORY SPENCER MARTIN III PHARMD

Table of content: DR. EMORY SPENCER MARTIN III PHARMD (NPI 1669817904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669817904 NPI number — DR. EMORY SPENCER MARTIN III PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
EMORY
Provider Middle Name:
SPENCER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
EMORY
Provider Other Middle Name:
SPENCER
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669817904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 S 31ST ST
Provider Second Line Business Mailing Address:
SWMH PHARMACY MS-01-055
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76508-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-724-3811
Provider Business Mailing Address Fax Number:
254-725-5017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 S 31ST ST
Provider Second Line Business Practice Location Address:
SWMH PHARMACY MS-01-055
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76508-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-724-3811
Provider Business Practice Location Address Fax Number:
254-725-5017
Provider Enumeration Date:
04/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1200X , with the licence number:  30166 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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