Provider Demographics
NPI:1023398419
Name:GUNDORF, LAURA ELIZABETH
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:GUNDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 FORBES DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-0002
Mailing Address - Country:US
Mailing Address - Phone:304-262-4697
Mailing Address - Fax:304-262-9029
Practice Address - Street 1:101 FORBES DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-0002
Practice Address - Country:US
Practice Address - Phone:304-262-4697
Practice Address - Fax:304-262-9029
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist