Provider Demographics
NPI:1457060717
Name:MAXIE, JOANNA KATHLEEN
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:KATHLEEN
Last Name:MAXIE
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 1:116 HICKORY HILL PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-1940
Mailing Address - Country:US
Mailing Address - Phone:601-674-0820
Mailing Address - Fax:
Practice Address - Street 1:116 HICKORY HILL PL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-1940
Practice Address - Country:US
Practice Address - Phone:601-674-0820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS100962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist