Provider Demographics
NPI:1043524150
Name:LIETZ, PHILLIP E (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:E
Last Name:LIETZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4146
Mailing Address - Country:US
Mailing Address - Phone:830-997-8809
Mailing Address - Fax:830-990-8751
Practice Address - Street 1:407 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4146
Practice Address - Country:US
Practice Address - Phone:830-997-8809
Practice Address - Fax:830-990-8751
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21589183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist