Provider Demographics
NPI:1285761726
Name:GRAVIL, MARTIN (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:GRAVIL
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2770
Mailing Address - Country:US
Mailing Address - Phone:270-739-0303
Mailing Address - Fax:270-234-0101
Practice Address - Street 1:311 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2230
Practice Address - Country:US
Practice Address - Phone:270-259-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012885183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY012885OtherKY PHARMACIST LICENSE