Provider Demographics
NPI:1205206687
Name:LAURIN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LAURIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 NOTT ST
Mailing Address - Street 2:MB#202
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-1812
Mailing Address - Country:US
Mailing Address - Phone:518-379-1865
Mailing Address - Fax:518-356-6978
Practice Address - Street 1:461 NOTT ST
Practice Address - Street 2:MB#202
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-1812
Practice Address - Country:US
Practice Address - Phone:518-379-1865
Practice Address - Fax:518-356-6978
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY033810OtherPHARMACIST LICENSE