Healthcare Provider Details

I. General information

NPI: 1952188310
Provider Name (Legal Business Name): MAXWELL ILNICKIS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 CHIEF EDDIE HOFFMAN HWY
BETHEL AK
99559-3362
US

IV. Provider business mailing address

PO BOX 3362
BETHEL AK
99559-3362
US

V. Phone/Fax

Practice location:
  • Phone: 907-543-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number249619
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04319800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number070688
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: