Provider Demographics
NPI:1326391012
Name:BLACK, LAIRD
Entity Type:Individual
Prefix:
First Name:LAIRD
Middle Name:
Last Name:BLACK
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 1:821 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97457-9334
Mailing Address - Country:US
Mailing Address - Phone:541-863-6383
Mailing Address - Fax:541-863-6023
Practice Address - Street 1:821 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MYRTLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97457-9334
Practice Address - Country:US
Practice Address - Phone:541-863-6383
Practice Address - Fax:541-863-6023
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR006925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist