Provider Demographics
NPI:1386913523
Name:MARTINDALE, JOHN BARRETT (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BARRETT
Last Name:MARTINDALE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4044 UPPER VALLEY CV
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6095
Mailing Address - Country:US
Mailing Address - Phone:901-826-7613
Mailing Address - Fax:
Practice Address - Street 1:1501 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1400
Practice Address - Country:US
Practice Address - Phone:662-342-9283
Practice Address - Fax:662-342-9289
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-09877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330158Medicaid