=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245637594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN LAU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2014
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 MULBERRY ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10013-4452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-693-6688
-----------------------------------------------------
Fax | 212-693-6677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 242 MARLTON PIKE W
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08002-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-428-0473
-----------------------------------------------------
Fax | 856-428-2568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28RI03674900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 060176
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------