Provider Demographics
NPI:1407910409
Name:ROGERS-WILSON, LAURA (RPH)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:ROGERS-WILSON
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 1:12494 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-4238
Mailing Address - Country:US
Mailing Address - Phone:814-282-0962
Mailing Address - Fax:
Practice Address - Street 1:1121 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3107
Practice Address - Country:US
Practice Address - Phone:814-333-1910
Practice Address - Fax:814-333-6673
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP440763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist