Provider Demographics
NPI:1255745923
Name:SUSIENKA, LAURI
Entity type:Individual
Prefix:
First Name:LAURI
Middle Name:
Last Name:SUSIENKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-1265
Mailing Address - Country:US
Mailing Address - Phone:908-306-8904
Mailing Address - Fax:908-306-1206
Practice Address - Street 1:55 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-1265
Practice Address - Country:US
Practice Address - Phone:908-306-8904
Practice Address - Fax:908-306-1206
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03606300183500000X
CTPCT.0012708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPCT.0012708OtherCT PHARMACIST LICENSE
NJ28RI03606300OtherNJ PHARMACIST LICENSE