Provider Demographics
NPI:1073846374
Name:PENCA, LAURA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:PENCA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 W TERRACE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1137
Mailing Address - Country:US
Mailing Address - Phone:317-413-0101
Mailing Address - Fax:
Practice Address - Street 1:34 W TERRACE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1137
Practice Address - Country:US
Practice Address - Phone:317-413-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053419-1183500000X
IN26019488A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist