Provider Demographics
NPI:1336559202
Name:BLACK, MARTHA (PHARM D)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
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 1:72901 SORREL DR
Mailing Address - Street 2:
Mailing Address - City:BRUCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3934
Mailing Address - Country:US
Mailing Address - Phone:586-292-7954
Mailing Address - Fax:
Practice Address - Street 1:36865 26 MILE RD
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MI
Practice Address - Zip Code:48048-3163
Practice Address - Country:US
Practice Address - Phone:586-716-5833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020341911835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy