Provider Demographics
NPI:1487268686
Name:MADDOX, BRAXTON (RPH)
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:
Last Name:MADDOX
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7910 FOUNTAIN MESA RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1532
Mailing Address - Country:US
Mailing Address - Phone:719-382-0427
Mailing Address - Fax:
Practice Address - Street 1:7910 FOUNTAIN MESA RD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1532
Practice Address - Country:US
Practice Address - Phone:719-382-0427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0023281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist