Provider Demographics
NPI:1477024776
Name:LAURENT, MARYRUSSELL WAGSTAFF (PHARMD, MSCR, BCPS)
Entity type:Individual
Prefix:
First Name:MARYRUSSELL
Middle Name:WAGSTAFF
Last Name:LAURENT
Suffix:
Gender:F
Credentials:PHARMD, MSCR, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 GREEN ST E
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 GREEN ST E
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4105
Practice Address - Country:US
Practice Address - Phone:252-243-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-12
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC268941835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care