Provider Demographics
NPI:1871725309
Name:MARTIN, BRUCE ERNEST (RPH)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ERNEST
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 1:114 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2325
Mailing Address - Country:US
Mailing Address - Phone:315-458-3363
Mailing Address - Fax:315-452-1603
Practice Address - Street 1:114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-2325
Practice Address - Country:US
Practice Address - Phone:315-458-3363
Practice Address - Fax:315-452-1603
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist