Provider Demographics
NPI:1508657487
Name:DUDENKOV, MAKSIM
Entity type:Individual
Prefix:
First Name:MAKSIM
Middle Name:
Last Name:DUDENKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11555 CENTRAL PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11555 CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2691
Practice Address - Country:US
Practice Address - Phone:904-885-2785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist