MEDICARE: MR. BOBBY DONALD MAISE RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	6060	AL
2	183500000X	Pharmacist	10548	FL

General Provider Information

NPI Number	:	1952526600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BOBBY DONALD MAISE RPH

Provider Business Mailing Address
First Line	:	821 CROSSHILL LANE
Second Line	:
City	:	WARRIOR
State	:	AL
Zip	:	35180-5540
Country	:	US
Telephone Number	:	205-647-6635
Fax Number	:	205-841-2405

Provider Business Practice Location Address
First Line	:	1152 EAST LAKE BLVD
Second Line	:
City	:	TARRANT
State	:	AL
Zip	:	35217
Country	:	US
Telephone Number	:	205-841-6421
Fax Number	:	205-841-2405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	07/08/2007

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