Provider Demographics
NPI:1649566548
Name:MAYNARD, DANETTE
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9833 N ALPINE RD
Mailing Address - Street 2:T1799
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-1681
Mailing Address - Country:US
Mailing Address - Phone:815-639-3301
Mailing Address - Fax:
Practice Address - Street 1:9833 N ALPINE RD
Practice Address - Street 2:T1799
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-1681
Practice Address - Country:US
Practice Address - Phone:815-639-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036243183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist