Provider Demographics
NPI:1447588397
Name:LO, LAISZE
Entity Type:Individual
Prefix:
First Name:LAISZE
Middle Name:
Last Name:LO
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 1:6980 GRAND AVE
Mailing Address - Street 2:69-80 GRAND AVE
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1828
Mailing Address - Country:US
Mailing Address - Phone:718-424-2781
Mailing Address - Fax:718-424-3335
Practice Address - Street 1:6980 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1828
Practice Address - Country:US
Practice Address - Phone:718-424-2781
Practice Address - Fax:718-424-3335
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist