Provider Demographics
NPI:1336476753
Name:MICCUCI, LAURA JANE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JANE
Last Name:MICCUCI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 ROUTES 5 & 20
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165
Mailing Address - Country:US
Mailing Address - Phone:315-539-5056
Mailing Address - Fax:
Practice Address - Street 1:1963 ROUTES 5 & 20
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165
Practice Address - Country:US
Practice Address - Phone:315-539-5056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist