Provider Demographics
NPI:1093311425
Name:TRAN, MAXWELL
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:TRAN
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:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:WHITEWRIGHT
Mailing Address - State:TX
Mailing Address - Zip Code:75491-0883
Mailing Address - Country:US
Mailing Address - Phone:469-734-5691
Mailing Address - Fax:
Practice Address - Street 1:100 N GREER BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-1409
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist