Provider Demographics
NPI:1811540636
Name:LASAK, AGNIESZKA MALGORZATA
Entity Type:Individual
Prefix:MRS
First Name:AGNIESZKA
Middle Name:MALGORZATA
Last Name:LASAK
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 1:6233 69TH PL # 2
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-1107
Mailing Address - Country:US
Mailing Address - Phone:347-514-0294
Mailing Address - Fax:
Practice Address - Street 1:831 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-6628
Practice Address - Country:US
Practice Address - Phone:718-389-0389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty