=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457546202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE MARIE MADDOX
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2007
-----------------------------------------------------
Last Update Date | 10/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2424 MARTIN LUTHER KING JR WAY
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94704-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-349-1141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2424 MARTIN LUTHER KING JR WAY
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94704-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-349-1141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 59839
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------