Provider Demographics
NPI:1558641530
Name:LAWLESS, GARY R (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:R
Last Name:LAWLESS
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:PO BOX 1251
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-1251
Mailing Address - Country:US
Mailing Address - Phone:715-358-3763
Mailing Address - Fax:715-358-5379
Practice Address - Street 1:9059 RAPPS RD
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9423
Practice Address - Country:US
Practice Address - Phone:715-358-3763
Practice Address - Fax:715-358-5379
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist