Provider Demographics
NPI:1063977320
Name:STACK, LAWRENCE (BS, RPH)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:STACK
Suffix:
Gender:M
Credentials:BS, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PROVIDENT CT
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-7266
Mailing Address - Country:US
Mailing Address - Phone:732-915-2999
Mailing Address - Fax:732-230-6615
Practice Address - Street 1:25 PROVIDENT CT
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-7266
Practice Address - Country:US
Practice Address - Phone:732-915-2999
Practice Address - Fax:732-230-6615
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01888200183500000X
MD10576183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI01888200OtherNJ BOARD OF PHARMACY
MD10576OtherMARYLAND BOARD OF PHARMACY