Provider Demographics
NPI:1952188310
Name:ILNICKIS, MAXWELL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:ILNICKIS
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 1:339 PARKINSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3537
Mailing Address - Country:US
Mailing Address - Phone:347-481-2242
Mailing Address - Fax:
Practice Address - Street 1:1133 INMAN AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1282
Practice Address - Country:US
Practice Address - Phone:908-753-0624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070688183500000X
NJ28RI04319800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist