Provider Demographics
NPI:1740495779
Name:STIDHAM, LAWRENCE DEAN (RPH)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:DEAN
Last Name:STIDHAM
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 1:2950 PLACID VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-5028
Mailing Address - Country:US
Mailing Address - Phone:863-465-6448
Mailing Address - Fax:
Practice Address - Street 1:224 E INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9603
Practice Address - Country:US
Practice Address - Phone:863-465-2291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0019943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist