Provider Demographics
NPI:1972887537
Name:LANE, LAURA JO (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JO
Last Name:LANE
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 1:1915 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-1095
Mailing Address - Country:US
Mailing Address - Phone:812-385-3296
Mailing Address - Fax:812-385-3580
Practice Address - Street 1:1915 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1095
Practice Address - Country:US
Practice Address - Phone:812-385-3296
Practice Address - Fax:812-385-3580
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022895A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist