Provider Demographics
NPI:1801192257
Name:GARDNER, LAURA JO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JO
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 HIGHWAY 30 W
Mailing Address - Street 2:
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824-9051
Mailing Address - Country:US
Mailing Address - Phone:662-365-5534
Mailing Address - Fax:
Practice Address - Street 1:41 S CENTER ST
Practice Address - Street 2:
Practice Address - City:POTTS CAMP
Practice Address - State:MS
Practice Address - Zip Code:38659-9531
Practice Address - Country:US
Practice Address - Phone:662-333-7782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE09336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist