Provider Demographics
NPI:1588949010
Name:NACKMAN, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:NACKMAN
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 1:10320 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2410
Mailing Address - Country:US
Mailing Address - Phone:703-591-1025
Mailing Address - Fax:703-591-1090
Practice Address - Street 1:10320 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2410
Practice Address - Country:US
Practice Address - Phone:703-591-1025
Practice Address - Fax:703-591-1090
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist