Provider Demographics
NPI:1124774229
Name:GAVRILYUK, LARISA AVRAMOVNA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:AVRAMOVNA
Last Name:GAVRILYUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26020 COOLIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1415
Mailing Address - Country:US
Mailing Address - Phone:248-545-8020
Mailing Address - Fax:248-582-3794
Practice Address - Street 1:14061 LUDLOW ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1352
Practice Address - Country:US
Practice Address - Phone:248-854-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5303008597OtherPHARMACY TECHNICIAN LICENSE