Provider Demographics
NPI:1316221807
Name:LAU, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:LAU
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 1:15 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-6905
Mailing Address - Country:US
Mailing Address - Phone:781-642-1105
Mailing Address - Fax:781-642-0990
Practice Address - Street 1:15 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-6905
Practice Address - Country:US
Practice Address - Phone:781-642-1105
Practice Address - Fax:781-642-0990
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20179183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist