Provider Demographics
NPI:1336238393
Name:MADDOX, BRANDON LANE (RPH, MBA)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:LANE
Last Name:MADDOX
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E. PINEHURST DR.
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2428
Mailing Address - Country:US
Mailing Address - Phone:605-254-2811
Mailing Address - Fax:866-462-5980
Practice Address - Street 1:217 E. PINEHURST DR.
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2428
Practice Address - Country:US
Practice Address - Phone:605-254-2811
Practice Address - Fax:866-462-5980
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13526183500000X
FLPS32120183500000X
SDR5430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist