Provider Demographics
NPI:1598043382
Name:NISONOFF, LAURENCE EVAN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:EVAN
Last Name:NISONOFF
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 MORAINE DR
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81657-4981
Mailing Address - Country:US
Mailing Address - Phone:970-476-7308
Mailing Address - Fax:970-476-7306
Practice Address - Street 1:105 EDWARDS VILLAGE BLVD STE G-107
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-9914
Practice Address - Country:US
Practice Address - Phone:970-476-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist