=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639087950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK MATTHEW LAWRENCE PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2026
-----------------------------------------------------
Last Update Date | 08/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5450 S GREEN ST
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84123-5632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-214-7671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1350 E MILLER AVE APT 504
-----------------------------------------------------
City | MILLCREEK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84106-4940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 14269654-1701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------