Provider Demographics
NPI:1215204458
Name:LAO, EANG
Entity Type:Individual
Prefix:
First Name:EANG
Middle Name:
Last Name:LAO
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 1:210 MOUNT HERMON RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4009
Mailing Address - Country:US
Mailing Address - Phone:831-430-9113
Mailing Address - Fax:831-430-9138
Practice Address - Street 1:210 MOUNT HERMON RD
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4009
Practice Address - Country:US
Practice Address - Phone:831-430-9113
Practice Address - Fax:831-430-9138
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH60362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist