Provider Demographics
NPI:1336319193
Name:ALLEN, MAX W (BS,DPH, CGP)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:W
Last Name:ALLEN
Suffix:
Gender:M
Credentials:BS,DPH, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19823 N 95TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4157
Mailing Address - Country:US
Mailing Address - Phone:623-523-3997
Mailing Address - Fax:
Practice Address - Street 1:19823 N 95TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4157
Practice Address - Country:US
Practice Address - Phone:623-523-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-08
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0144851835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric