Provider Demographics
NPI:1831379171
Name:O'HERN, LAURIE ANN
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ANN
Last Name:O'HERN
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 1:9369 WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-9441
Mailing Address - Country:US
Mailing Address - Phone:315-668-9062
Mailing Address - Fax:
Practice Address - Street 1:519 BUTTERNUT ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-2628
Practice Address - Country:US
Practice Address - Phone:315-471-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-03
Last Update Date:2007-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist