Provider Demographics
NPI:1922603406
Name:KING, MAXWELL CLARK II (BPH)
Entity Type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:CLARK
Last Name:KING
Suffix:II
Gender:M
Credentials:BPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 3RD ST.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6634
Mailing Address - Country:US
Mailing Address - Phone:904-246-7596
Mailing Address - Fax:
Practice Address - Street 1:1504 3RD ST.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6634
Practice Address - Country:US
Practice Address - Phone:904-246-7596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS018393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist