Provider Demographics
NPI:1104124262
Name:LAIKEN, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LAIKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 PROSPECT AVE
Mailing Address - Street 2:APT 12-2B
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-2256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37 OLD HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809-1342
Practice Address - Country:US
Practice Address - Phone:410-218-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03357200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist