Healthcare Provider Details

I. General information

NPI: 1639087950
Provider Name (Legal Business Name): JACK MATTHEW LAWRENCE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 S GREEN ST
SALT LAKE CITY UT
84123-5632
US

IV. Provider business mailing address

1350 E MILLER AVE APT 504
MILLCREEK UT
84106-4940
US

V. Phone/Fax

Practice location:
  • Phone: 801-214-7671
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14269654-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: