Provider Demographics
NPI:1720412166
Name:LYUTOV, LISA ANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:LYUTOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551736
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:860 A1A N
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-3212
Practice Address - Country:US
Practice Address - Phone:904-543-0762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51020183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist