Provider Demographics
NPI:1407004385
Name:LAGERSTROM, GARY MICHAEL (PHARM D)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:LAGERSTROM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9230 SKY ISLAND DR E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391
Mailing Address - Country:US
Mailing Address - Phone:253-750-6050
Mailing Address - Fax:253-750-6055
Practice Address - Street 1:9230 SKY ISLAND DRIVE EAST
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-0000
Practice Address - Country:US
Practice Address - Phone:253-750-6050
Practice Address - Fax:253-750-6055
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00065014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist