Provider Demographics
NPI:1700876463
Name:LAUREN PHARMACY INC
Entity Type:Organization
Organization Name:LAUREN PHARMACY INC
Other - Org Name:LAUREL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:BS RPH
Authorized Official - Phone:818-896-1104
Mailing Address - Street 1:13686 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-3616
Mailing Address - Country:US
Mailing Address - Phone:818-896-1104
Mailing Address - Fax:818-896-7299
Practice Address - Street 1:13686 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-3616
Practice Address - Country:US
Practice Address - Phone:818-896-1104
Practice Address - Fax:818-896-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPH7327640333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPH732764Medicaid