Provider Demographics
NPI:1598846461
Name:MAXWELL, LARRY ALLEN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ALLEN
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1404 NW MIMOSA CIR
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1868
Mailing Address - Country:US
Mailing Address - Phone:918-967-8229
Mailing Address - Fax:918-967-8211
Practice Address - Street 1:501 NW H ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1627
Practice Address - Country:US
Practice Address - Phone:918-967-8877
Practice Address - Fax:918-967-8211
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8551Medicare UPIN