Healthcare Provider Details

I. General information

NPI: 1396073458
Provider Name (Legal Business Name): LAURA VISCOVIC RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MAIN ST
HACKENSACK NJ
07601-5913
US

IV. Provider business mailing address

630 MAIN ST
HACKENSACK NJ
07601-5913
US

V. Phone/Fax

Practice location:
  • Phone: 201-678-0569
  • Fax:
Mailing address:
  • Phone: 201-678-0569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI02093300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20052422
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: