1407004385 NPI number — GARY MICHAEL LAGERSTROM PHARM D

Table of content: GARY MICHAEL LAGERSTROM PHARM D (NPI 1407004385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407004385 NPI number — GARY MICHAEL LAGERSTROM PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAGERSTROM
Provider First Name:
GARY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407004385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9230 SKY ISLAND DR E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNEY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-750-6050
Provider Business Mailing Address Fax Number:
253-750-6055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9230 SKY ISLAND DRIVE EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-750-6050
Provider Business Practice Location Address Fax Number:
253-750-6055
Provider Enumeration Date:
09/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PH00065014 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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