Healthcare Provider Details

I. General information

NPI: 1225725682
Provider Name (Legal Business Name): MAIA RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 EDINBOROUGH DR APT 816
DURHAM NC
27703-8497
US

IV. Provider business mailing address

800 EDINBOROUGH DR. APT. 816
DURHAM NC
27703
US

V. Phone/Fax

Practice location:
  • Phone: 919-717-6836
  • Fax:
Mailing address:
  • Phone: 919-717-6836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number30037014
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number30037014
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: