Provider Demographics
NPI:1538423918
Name:MARTIN, GERALD WESLEY (RPH)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:WESLEY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-2505
Mailing Address - Country:US
Mailing Address - Phone:970-245-8078
Mailing Address - Fax:970-245-8078
Practice Address - Street 1:453 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81507-2505
Practice Address - Country:US
Practice Address - Phone:970-245-8078
Practice Address - Fax:970-245-8078
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist