Provider Demographics
NPI:1487936431
Name:MOLLETTE, LAUREN M (BS)
Entity type:Individual
Prefix:MISS
First Name:LAUREN
Middle Name:M
Last Name:MOLLETTE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2441
Mailing Address - Country:US
Mailing Address - Phone:708-366-9534
Mailing Address - Fax:
Practice Address - Street 1:7200 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2441
Practice Address - Country:US
Practice Address - Phone:708-366-9534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist