Provider Demographics
NPI:1265710842
Name:FORTUNA, LAURA (PHARMD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:GRUBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:MAIL STOP: 21111B
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1309
Mailing Address - Country:US
Mailing Address - Phone:952-883-6807
Mailing Address - Fax:985-853-8829
Practice Address - Street 1:401 PHALEN BLVD
Practice Address - Street 2:MAIL STOP: 41103F
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-7600
Practice Address - Fax:651-254-7623
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist