Provider Demographics
NPI:1871283655
Name:MARTIN, MACY
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 EXCALIBUR DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-1818
Mailing Address - Country:US
Mailing Address - Phone:972-345-0620
Mailing Address - Fax:
Practice Address - Street 1:949 WILLIAM D FITCH PKWY
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-4638
Practice Address - Country:US
Practice Address - Phone:979-690-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist