Provider Demographics
NPI:1902181035
Name:SEWALL, LAURA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SEWALL
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 1:207 HIDDEN RIDGES WAY
Mailing Address - Street 2:
Mailing Address - City:COMBINED LOCKS
Mailing Address - State:WI
Mailing Address - Zip Code:54113-1300
Mailing Address - Country:US
Mailing Address - Phone:920-716-4700
Mailing Address - Fax:
Practice Address - Street 1:1150 SPRINGHURST DR
Practice Address - Street 2:SUITE #206
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5950
Practice Address - Country:US
Practice Address - Phone:920-497-0985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16441-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist