Provider Demographics
NPI:1184353906
Name:SPURLOCK, MAYNARD B (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MAYNARD
Middle Name:B
Last Name:SPURLOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 NEW MOODY LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9154
Mailing Address - Country:US
Mailing Address - Phone:502-222-3352
Mailing Address - Fax:
Practice Address - Street 1:1025 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9154
Practice Address - Country:US
Practice Address - Phone:502-222-3352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
568946544OtherBCBS
5874OtherHEALTH PARTNERS
KY236Medicaid