Provider Demographics
NPI:1497078240
Name:DAVIS, LAURA ROSE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ROSE
Last Name:DAVIS
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 1:241 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302
Mailing Address - Country:US
Mailing Address - Phone:518-347-2206
Mailing Address - Fax:
Practice Address - Street 1:241 MOHAWK AVE
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-2128
Practice Address - Country:US
Practice Address - Phone:518-347-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist