Provider Demographics
NPI:1225643380
Name:ULRICH, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ULRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 MACKENZIE LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3577
Mailing Address - Country:US
Mailing Address - Phone:817-718-1440
Mailing Address - Fax:
Practice Address - Street 1:2013 KELLY LN
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-7879
Practice Address - Country:US
Practice Address - Phone:512-990-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX466880Medicaid