Provider Demographics
NPI:1215350855
Name:BYRD, MARTELLE
Entity type:Individual
Prefix:
First Name:MARTELLE
Middle Name:
Last Name:BYRD
Suffix:
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 1:6012 DORCHESTER PL
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-9370
Mailing Address - Country:US
Mailing Address - Phone:850-974-4000
Mailing Address - Fax:
Practice Address - Street 1:1355 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-1713
Practice Address - Country:US
Practice Address - Phone:850-603-6187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10215183500000X
FLPS19355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist