Provider Demographics
NPI:1720360332
Name:DAWSON, MARK W (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:DAWSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 AJIJAAK AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8330
Mailing Address - Country:US
Mailing Address - Phone:231-242-1750
Mailing Address - Fax:231-242-1755
Practice Address - Street 1:710 SPRING ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2851
Practice Address - Country:US
Practice Address - Phone:231-348-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302410739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist