Provider Demographics
NPI:1043962533
Name:PRENTICE, MAXIM RENNIE
Entity type:Individual
Prefix:
First Name:MAXIM
Middle Name:RENNIE
Last Name:PRENTICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28515 N NORTH VALLEY PKWY APT 1129
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5411
Mailing Address - Country:US
Mailing Address - Phone:480-569-5174
Mailing Address - Fax:
Practice Address - Street 1:2415 E UNION HILLS DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-3146
Practice Address - Country:US
Practice Address - Phone:602-867-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS025716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist