Provider Demographics
NPI:1083026991
Name:MARTIN, DALE JEROME JR
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:JEROME
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 E. CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016
Mailing Address - Country:US
Mailing Address - Phone:602-277-1727
Mailing Address - Fax:602-277-4260
Practice Address - Street 1:1610 E. CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-277-1727
Practice Address - Fax:602-277-4260
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist