Provider Demographics
NPI:1255484507
Name:LAIRD, BRUCE L (RPH)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:LAIRD
Suffix:
Gender:M
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:N5431 ROCKY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-8498
Mailing Address - Country:US
Mailing Address - Phone:715-635-8312
Mailing Address - Fax:
Practice Address - Street 1:819 ASH ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1201
Practice Address - Country:US
Practice Address - Phone:715-635-2111
Practice Address - Fax:715-635-2504
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8044-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist