Provider Demographics
NPI:1558781138
Name:LAU, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:LAU
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 1:13101 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3837
Mailing Address - Country:US
Mailing Address - Phone:305-450-5029
Mailing Address - Fax:
Practice Address - Street 1:13101 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3837
Practice Address - Country:US
Practice Address - Phone:305-450-5029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 34791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist