Provider Demographics
NPI:1700986353
Name:MAKSOUR, MANALE
Entity type:Individual
Prefix:MRS
First Name:MANALE
Middle Name:
Last Name:MAKSOUR
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 1:15252 N 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3412
Mailing Address - Country:US
Mailing Address - Phone:480-385-8830
Mailing Address - Fax:
Practice Address - Street 1:15252 N 54TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3412
Practice Address - Country:US
Practice Address - Phone:480-385-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist