Provider Demographics
NPI:1477743169
Name:LAWRENCE, MARY CAROL
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:LAWRENCE
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 1:7900 BAILEY COVE RD SE STE R
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-3330
Mailing Address - Country:US
Mailing Address - Phone:256-650-2336
Mailing Address - Fax:256-650-2337
Practice Address - Street 1:7900 BAILEY COVE RD SE STE R
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-3330
Practice Address - Country:US
Practice Address - Phone:256-650-2335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-28
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL3633Medicaid