Provider Demographics
NPI:1225135114
Name:MAXSON MEDICAL PHARMACY INC
Entity Type:Organization
Organization Name:MAXSON MEDICAL PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KINGKWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:RPH REGISTERED PHARM
Authorized Official - Phone:626-338-1143
Mailing Address - Street 1:933 SOUTH SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790
Mailing Address - Country:US
Mailing Address - Phone:626-338-1143
Mailing Address - Fax:626-962-8007
Practice Address - Street 1:933 SOUTH SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-338-1143
Practice Address - Fax:626-962-8007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY33095333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA330950Medicaid
CAPHA330950Medicaid