Provider Demographics
NPI:1114034451
Name:MAXSONS PHARMACY INC
Entity Type:Organization
Organization Name:MAXSONS PHARMACY INC
Other - Org Name:MAXSONS DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HERZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-789-0301
Mailing Address - Street 1:14070 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3542
Mailing Address - Country:US
Mailing Address - Phone:818-789-0301
Mailing Address - Fax:818-789-2711
Practice Address - Street 1:14070 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3542
Practice Address - Country:US
Practice Address - Phone:818-789-0301
Practice Address - Fax:818-789-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY392293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA392290Medicaid
2115868OtherPK
CAPHA392290Medicaid