Provider Demographics
NPI:1073124814
Name:LUTZ, DAVID MICHAEL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:LUTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 N WALLACE WILKINSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-3017
Mailing Address - Country:US
Mailing Address - Phone:606-787-5574
Mailing Address - Fax:606-787-5604
Practice Address - Street 1:343 N WALLACE WILKINSON BLVD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3017
Practice Address - Country:US
Practice Address - Phone:606-787-5574
Practice Address - Fax:606-787-5604
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011978183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist