Provider Demographics
NPI:1548556772
Name:MAXWELL, ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2035
Mailing Address - Country:US
Mailing Address - Phone:208-678-3286
Mailing Address - Fax:208-678-1679
Practice Address - Street 1:937 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2035
Practice Address - Country:US
Practice Address - Phone:208-678-3286
Practice Address - Fax:208-678-1679
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3936183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist