Provider Demographics
NPI:1487425252
Name:MARTIN, KELLY (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:GABEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:201 HARBIN AVE
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-2441
Mailing Address - Country:US
Mailing Address - Phone:214-682-5193
Mailing Address - Fax:
Practice Address - Street 1:196 SHAWNEE MALL DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1337
Practice Address - Country:US
Practice Address - Phone:405-878-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37757183500000X
OK11696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacist