Healthcare Provider Details

I. General information

NPI: 1205206687
Provider Name (Legal Business Name): MARK LAURIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 NOTT ST MB#202
SCHENECTADY NY
12308-1812
US

IV. Provider business mailing address

461 NOTT ST MB#202
SCHENECTADY NY
12308-1812
US

V. Phone/Fax

Practice location:
  • Phone: 518-379-1865
  • Fax: 518-356-6978
Mailing address:
  • Phone: 518-379-1865
  • Fax: 518-356-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033810
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: