Provider Demographics
NPI:1770663569
Name:GARDON, LAWRENCE (RPH)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:GARDON
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 1:2200 SPRINGPORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1432
Mailing Address - Country:US
Mailing Address - Phone:517-787-7053
Mailing Address - Fax:
Practice Address - Street 1:2200 SPRINGPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1432
Practice Address - Country:US
Practice Address - Phone:517-787-7053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist