Provider Demographics
NPI:1932410685
Name:MARTIN, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
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 1:1505 JOHNSON DR
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3358
Mailing Address - Country:US
Mailing Address - Phone:423-317-7303
Mailing Address - Fax:
Practice Address - Street 1:2825 W ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3216
Practice Address - Country:US
Practice Address - Phone:423-317-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022977A183500000X, 1835P0018X
TN33251183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN361924025OtherEMPLOYER IDENTIFICATION NUMBER