Provider Demographics
NPI:1427238930
Name:MAXSON, PHYLLIS ANN (PHARMACIST)
Entity type:Individual
Prefix:MISS
First Name:PHYLLIS
Middle Name:ANN
Last Name:MAXSON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 ERIE BLVD W
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2948
Mailing Address - Country:US
Mailing Address - Phone:315-337-4120
Mailing Address - Fax:
Practice Address - Street 1:1124 ERIE BLVD W
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2948
Practice Address - Country:US
Practice Address - Phone:315-337-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist