=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851002364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAXWELL PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2022
-----------------------------------------------------
Last Update Date | 12/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3416 CLIO RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48504-1837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-471-3333
-----------------------------------------------------
Fax | 810-553-9138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3416 CLIO RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48504-1837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-471-3333
-----------------------------------------------------
Fax | 810-553-9138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | AJAYKUMAR GAJERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-986-8675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------