Provider Demographics
NPI:1972898674
Name:LAVECK, SUE (5302022995)
Entity type:Individual
Prefix:MRS
First Name:SUE
Middle Name:
Last Name:LAVECK
Suffix:
Gender:F
Credentials:5302022995
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14099 PARDEE RD
Mailing Address - Street 2:T0280
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4792
Mailing Address - Country:US
Mailing Address - Phone:734-288-0005
Mailing Address - Fax:734-288-0005
Practice Address - Street 1:14099 PARDEE RD
Practice Address - Street 2:T0280
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4792
Practice Address - Country:US
Practice Address - Phone:734-288-0005
Practice Address - Fax:734-288-0005
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist