Provider Demographics
NPI:1851821250
Name:LAILSON, VICTORIA LAYNE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LAYNE
Last Name:LAILSON
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 1:40525 SUNFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5890
Mailing Address - Country:US
Mailing Address - Phone:843-446-2744
Mailing Address - Fax:
Practice Address - Street 1:31021 TEMECULA PKWY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2991
Practice Address - Country:US
Practice Address - Phone:951-303-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist