Provider Demographics
NPI:1285923508
Name:MARTIN, ROBERT WILLIAM
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:MARTIN
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 1:1106 S BUSINESS HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:MO
Mailing Address - Zip Code:63334-5233
Mailing Address - Country:US
Mailing Address - Phone:573-324-3383
Mailing Address - Fax:573-324-6388
Practice Address - Street 1:1106 S BUSINESS HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-5233
Practice Address - Country:US
Practice Address - Phone:573-324-3383
Practice Address - Fax:573-324-6388
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600121420Medicaid