Provider Demographics
NPI:1689862690
Name:GANSEN, LAURA P (RPH)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:P
Last Name:GANSEN
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 1:1731 W RIDGEWAY AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-4595
Mailing Address - Country:US
Mailing Address - Phone:319-833-5725
Mailing Address - Fax:319-833-5729
Practice Address - Street 1:1731 W RIDGEWAY AVE
Practice Address - Street 2:STE. 200
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4595
Practice Address - Country:US
Practice Address - Phone:319-833-5725
Practice Address - Fax:319-833-5729
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17474183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist