Provider Demographics
NPI:1073191961
Name:KIRK, LAURA WALIGURA
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:WALIGURA
Last Name:KIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:WALIGURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2891 OLD DECATUR RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 TECHNOLOGY CT SE STE B
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5201
Practice Address - Country:US
Practice Address - Phone:866-437-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017184183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist