Provider Demographics
NPI:1306626049
Name:RADZIEWICZ, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:RADZIEWICZ
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 1:66 ONEILL AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6827
Mailing Address - Country:US
Mailing Address - Phone:631-901-7977
Mailing Address - Fax:
Practice Address - Street 1:1825 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4666
Practice Address - Country:US
Practice Address - Phone:631-952-7752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist