Basic Information
Provider Information | |||||||||
NPI: | 1962583542 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 SUMMERFIELD DR | ||||||||
Address2: |   | ||||||||
City: | BRYANT | ||||||||
State: | AR | ||||||||
PostalCode: | 720223277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016532890 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | CENTRAL ARKANSAS VETERANS HEALTHCARE SYSTEM 119LR | ||||||||
Address2: | 4300 WEST 7TH STREET | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722055484 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5012576364 | ||||||||
FaxNumber: | 5012576329 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PD10359 | AR | X |   | Pharmacy Service Providers | Pharmacist |   | 1835P1200X | PD10359 | AR | X |   | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.