Provider Demographics
NPI:1083996219
Name:MAYNARD, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MAYNARD
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 1:3 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WEST LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03784-1657
Mailing Address - Country:US
Mailing Address - Phone:603-298-5796
Mailing Address - Fax:
Practice Address - Street 1:3 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WEST LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03784-1657
Practice Address - Country:US
Practice Address - Phone:603-298-5796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3151183500000X
MAPH23950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist