Provider Demographics
NPI:1073807913
Name:GRANNEMAN, LAURA LEIGH (RPH)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LEIGH
Last Name:GRANNEMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6636 N 73RD PLZ
Mailing Address - Street 2:T2010
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-1803
Mailing Address - Country:US
Mailing Address - Phone:402-573-2221
Mailing Address - Fax:402-573-2231
Practice Address - Street 1:6636 N 73RD PLZ
Practice Address - Street 2:T2010
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1803
Practice Address - Country:US
Practice Address - Phone:402-650-1673
Practice Address - Fax:402-573-2231
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist