Provider Demographics
NPI:1407936347
Name:LUEA, MARK GREGORY (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:LUEA
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 1:8021 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-1342
Mailing Address - Country:US
Mailing Address - Phone:810-635-3355
Mailing Address - Fax:810-635-9856
Practice Address - Street 1:8021 MILLER RD
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-1342
Practice Address - Country:US
Practice Address - Phone:810-635-3355
Practice Address - Fax:810-635-9856
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301000555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2333730OtherNABP NUMBER
MI2541912Medicaid
MI2541912Medicaid
MI5032910001Medicare ID - Type Unspecified