Provider Demographics
NPI:1447492541
Name:CUNNINGHAM, LAURA ANN KOCH (RPH)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN KOCH
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:11216 CHARIOT CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2112
Mailing Address - Country:US
Mailing Address - Phone:260-479-8030
Mailing Address - Fax:
Practice Address - Street 1:1502 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-3317
Practice Address - Country:US
Practice Address - Phone:419-394-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03216469183500000X
IN26022252A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist