Provider Demographics
NPI:1083006910
Name:LUETKE, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LUETKE
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 1:405 N WALES RD
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9728
Mailing Address - Country:US
Mailing Address - Phone:262-968-9570
Mailing Address - Fax:
Practice Address - Street 1:405 N WALES RD
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9728
Practice Address - Country:US
Practice Address - Phone:262-968-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1665240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist