Provider Demographics
NPI:1033143276
Name:MILLER, MAXINE JAN
Entity type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:JAN
Last Name:MILLER
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 1:9006 SUMMER CREST DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093
Mailing Address - Country:US
Mailing Address - Phone:801-571-4503
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84148
Practice Address - Country:US
Practice Address - Phone:801-582-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist