Basic Information
| Provider Information | |||||||||
| NPI: | 1881059392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 N VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731183039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058311031 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 S BLISS AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2015 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 15825 | OK | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.