Provider Demographics
NPI:1922330711
Name:FAUL, THERESA LASARSO (RPH)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LASARSO
Last Name:FAUL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BLACKSMITH DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4428
Mailing Address - Country:US
Mailing Address - Phone:518-899-8107
Mailing Address - Fax:518-899-2968
Practice Address - Street 1:10 BLACKSMITH DR
Practice Address - Street 2:SUITE 2
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4428
Practice Address - Country:US
Practice Address - Phone:518-899-8107
Practice Address - Fax:518-899-2968
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist