Provider Demographics
NPI:1306447529
Name:MARTIN, COTY PRENTICE (DOCTOR OF PHARMACY)
Entity type:Individual
Prefix:
First Name:COTY
Middle Name:PRENTICE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-8017
Mailing Address - Country:US
Mailing Address - Phone:870-740-5044
Mailing Address - Fax:
Practice Address - Street 1:400 W MOULTRIE DR
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1716
Practice Address - Country:US
Practice Address - Phone:870-763-7951
Practice Address - Fax:870-763-7958
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15131183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist