Provider Demographics
NPI:1912544099
Name:LAO, JEEMENG
Entity Type:Individual
Prefix:
First Name:JEEMENG
Middle Name:
Last Name:LAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-2948
Mailing Address - Country:US
Mailing Address - Phone:510-269-7739
Mailing Address - Fax:
Practice Address - Street 1:31836 ALVARADO BLVD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-3913
Practice Address - Country:US
Practice Address - Phone:510-489-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-07
Last Update Date:2019-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist