Provider Demographics
NPI:1689401697
Name:MARTIN, DURAND DALE JR
Entity type:Individual
Prefix:
First Name:DURAND
Middle Name:DALE
Last Name:MARTIN
Suffix:JR
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 1:1542 PATINA DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-4519
Mailing Address - Country:US
Mailing Address - Phone:901-605-0520
Mailing Address - Fax:
Practice Address - Street 1:8046 MACON RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-8531
Practice Address - Country:US
Practice Address - Phone:901-753-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist