Provider Demographics
NPI:1003427220
Name:HERTZOG, LAUREN MICHELLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:MICHELLE
Last Name:HERTZOG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 LORI LN
Mailing Address - Street 2:
Mailing Address - City:MERTZTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19539-9123
Mailing Address - Country:US
Mailing Address - Phone:484-892-9638
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist