MEDICARE: MRS. LAURA P. GANSEN R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	17474	IA

General Provider Information

NPI Number	:	1689862690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA P. GANSEN R.PH.

Provider Business Mailing Address
First Line	:	1731 W RIDGEWAY AVE
Second Line	:	STE. 200
City	:	WATERLOO
State	:	IA
Zip	:	50701-4595
Country	:	US
Telephone Number	:	319-833-5725
Fax Number	:	319-833-5729

Provider Business Practice Location Address
First Line	:	1731 W RIDGEWAY AVE
Second Line	:	STE. 200
City	:	WATERLOO
State	:	IA
Zip	:	50701-4595
Country	:	US
Telephone Number	:	319-833-5725
Fax Number	:	319-833-5729

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2007
Last Update Date	:	10/04/2007

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