=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114356318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAIR ELAINE MAXWELL PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2013
-----------------------------------------------------
Last Update Date | 11/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 HARTFORD ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-2134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-423-6880
-----------------------------------------------------
Fax | 765-423-6569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 HARTFORD ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 26023354A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------