Provider Demographics
NPI:1437562303
Name:SHACK, LAURA BRADLEY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:BRADLEY
Last Name:SHACK
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 1:535 BRIGHTMORE DOWNS
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-6705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 BRIGHTMORE DOWNS
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-6705
Practice Address - Country:US
Practice Address - Phone:770-559-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-08
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist