Basic Information
| Provider Information | |||||||||
| NPI: | 1699201954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LUNETTE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | R.PH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7083 W 48TH ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494129508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318935488 | ||||||||
| FaxNumber: | 2318935493 | ||||||||
| Practice Location | |||||||||
| Address1: | 7083 W 48TH ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494129508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318935488 | ||||||||
| FaxNumber: | 2318935493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2017 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302410347 | MI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.