Provider Demographics
NPI:1588996532
Name:MAVIS, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:GAWRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4872 SHIRLEY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14111-9786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 N FRENCH RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2009
Practice Address - Country:US
Practice Address - Phone:716-691-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053618-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist