Provider Demographics
NPI:1366073231
Name:LAWRENCE, AMANDA M
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:MI
Mailing Address - Zip Code:48457-9004
Mailing Address - Country:US
Mailing Address - Phone:810-639-0049
Mailing Address - Fax:
Practice Address - Street 1:225 E STATE ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:MI
Practice Address - Zip Code:48457-9004
Practice Address - Country:US
Practice Address - Phone:810-639-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist