Provider Demographics
NPI:1053772657
Name:OURS, CAROL LEA (RPH, AEC)
Entity type:Individual
Prefix:
First Name:CAROL LEA
Middle Name:
Last Name:OURS
Suffix:
Gender:F
Credentials:RPH, AEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ANNIE GEORGE DR
Mailing Address - Street 2:
Mailing Address - City:MASHANTUCKET
Mailing Address - State:CT
Mailing Address - Zip Code:06338-3801
Mailing Address - Country:US
Mailing Address - Phone:888-779-6362
Mailing Address - Fax:800-779-6329
Practice Address - Street 1:1 ANNIE GEORGE DR
Practice Address - Street 2:
Practice Address - City:MASHANTUCKET
Practice Address - State:CT
Practice Address - Zip Code:06338-3801
Practice Address - Country:US
Practice Address - Phone:888-779-6362
Practice Address - Fax:800-779-6329
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8112183500000X
RI3684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist