Provider Demographics
NPI:1659762029
Name:LANNERD, MARY JEAN (CPHT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:LANNERD
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2073
Mailing Address - Country:US
Mailing Address - Phone:631-208-9354
Mailing Address - Fax:631-740-3243
Practice Address - Street 1:1150 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2073
Practice Address - Country:US
Practice Address - Phone:631-208-9354
Practice Address - Fax:631-740-3243
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
060103261265662183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician