Provider Demographics
NPI:1043827298
Name:FITZGERALD, LAUREN RENE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:RENE
Last Name:FITZGERALD
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 1:840 W SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-3533
Mailing Address - Country:US
Mailing Address - Phone:231-759-8587
Mailing Address - Fax:231-759-6108
Practice Address - Street 1:840 W SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-3533
Practice Address - Country:US
Practice Address - Phone:231-759-8587
Practice Address - Fax:231-759-6108
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303020183183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician