Provider Demographics
NPI:1194313593
Name:MARTIN, ANGELA DAWN
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7759 ELMORE RD
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-3528
Mailing Address - Country:US
Mailing Address - Phone:208-740-9750
Mailing Address - Fax:
Practice Address - Street 1:7402 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8411
Practice Address - Country:US
Practice Address - Phone:208-375-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP9175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist