Provider Demographics
NPI:1902217250
Name:LAM, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8850 SHAVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-6155
Mailing Address - Country:US
Mailing Address - Phone:269-321-4333
Mailing Address - Fax:
Practice Address - Street 1:8850 SHAVER RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-6155
Practice Address - Country:US
Practice Address - Phone:269-321-4333
Practice Address - Fax:269-321-4365
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020371001835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy