Provider Demographics
NPI:1497278535
Name:LAWRENCE, MICHAEL DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17400 RESERVATION RD
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-8801
Mailing Address - Country:US
Mailing Address - Phone:360-466-3167
Mailing Address - Fax:360-466-5528
Practice Address - Street 1:17400 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8801
Practice Address - Country:US
Practice Address - Phone:360-466-3167
Practice Address - Fax:360-466-5528
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-470291835P0018X, 1835P0018X
WAPH60769543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPHA-PHA-LIC-47029Medicaid