Provider Demographics
NPI:1255672416
Name:SHANE, LAURA (PHARMD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SHANE
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 1:19300 S HAMILTON AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4411
Mailing Address - Country:US
Mailing Address - Phone:310-771-0619
Mailing Address - Fax:310-771-0621
Practice Address - Street 1:19300 S HAMILTON AVE STE 170
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4411
Practice Address - Country:US
Practice Address - Phone:310-771-0619
Practice Address - Fax:310-771-0621
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist