Provider Demographics
NPI:1669108684
Name:PULTORAK, LAURA (PHARMD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PULTORAK
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 1:1311 N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2299
Mailing Address - Country:US
Mailing Address - Phone:970-564-2190
Mailing Address - Fax:
Practice Address - Street 1:1311 N MILDRED RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2299
Practice Address - Country:US
Practice Address - Phone:970-564-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.00219611835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology