Provider Demographics
NPI:1609130103
Name:CANTRELL, LAURA BROOKE
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:BROOKE
Last Name:CANTRELL
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 1:27055 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-9250
Mailing Address - Country:US
Mailing Address - Phone:253-839-1693
Mailing Address - Fax:253-839-2876
Practice Address - Street 1:27055 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-9250
Practice Address - Country:US
Practice Address - Phone:253-839-1693
Practice Address - Fax:253-839-2876
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA000067937183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician