Provider Demographics
NPI:1558634428
Name:SORENSON, LAVONNE WAYNE (RPH)
Entity Type:Individual
Prefix:MR
First Name:LAVONNE
Middle Name:WAYNE
Last Name:SORENSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29370 DRYDEN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-1711
Mailing Address - Country:US
Mailing Address - Phone:760-256-3865
Mailing Address - Fax:
Practice Address - Street 1:29370 DRYDEN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-1711
Practice Address - Country:US
Practice Address - Phone:760-256-3865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist