Provider Demographics
NPI:1881172872
Name:PRAIRIE, LAUREL (RPH)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:PRAIRIE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11206 QUEBEC LN N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3226
Mailing Address - Country:US
Mailing Address - Phone:612-210-7392
Mailing Address - Fax:
Practice Address - Street 1:1960 TWIN LAKES PKWY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1324
Practice Address - Country:US
Practice Address - Phone:612-788-1478
Practice Address - Fax:612-788-1521
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist