Provider Demographics
NPI:1548861255
Name:MAXWELL, MARK ALAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:MAXWELL
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 1:9415 DEL RIO DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5997
Mailing Address - Country:US
Mailing Address - Phone:402-646-5988
Mailing Address - Fax:
Practice Address - Street 1:8700 ANDERMATT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68526-9653
Practice Address - Country:US
Practice Address - Phone:402-484-6342
Practice Address - Fax:402-484-6349
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist