Provider Demographics
NPI:1073800959
Name:LIVENGOOD, LAURIE SIDES (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:SIDES
Last Name:LIVENGOOD
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 1:1040 HANES MALL BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1309
Mailing Address - Country:US
Mailing Address - Phone:336-774-9623
Mailing Address - Fax:336-774-9623
Practice Address - Street 1:1040 HANES MALL BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1309
Practice Address - Country:US
Practice Address - Phone:336-774-9623
Practice Address - Fax:336-774-9623
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist