Healthcare Provider Details

I. General information

NPI: 1316047053
Provider Name (Legal Business Name): MR. DONALD EDWARD MAYDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E FERGUSON AVE
WOOD RIVER IL
62095-2146
US

IV. Provider business mailing address

5910 STATE ROUTE 4
ALHAMBRA IL
62001-1910
US

V. Phone/Fax

Practice location:
  • Phone: 618-254-6223
  • Fax:
Mailing address:
  • Phone: 618-488-7126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: