Provider Demographics
NPI:1760704829
Name:MAXWELL, GAIL (RPH)
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 AIR PARK DR
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7360
Mailing Address - Country:US
Mailing Address - Phone:631-981-0034
Mailing Address - Fax:631-981-0722
Practice Address - Street 1:80 AIR PARK DR
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7360
Practice Address - Country:US
Practice Address - Phone:631-981-0034
Practice Address - Fax:631-981-0722
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02118303Medicaid