Provider Demographics
NPI:1063186286
Name:MADDOX, CHARLES (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:MADDOX
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 1:2026 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-3832
Practice Address - Country:US
Practice Address - Phone:308-762-1258
Practice Address - Fax:308-762-2126
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16186183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist