Provider Demographics
NPI:1992747448
Name:KOLLENBERG, LAWRENCE OWEN (RPH)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:OWEN
Last Name:KOLLENBERG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 CHARLEMAGNE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2908
Mailing Address - Country:US
Mailing Address - Phone:904-543-7681
Mailing Address - Fax:
Practice Address - Street 1:316 CHARLEMAGNE CIR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2908
Practice Address - Country:US
Practice Address - Phone:904-543-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS35765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist