Provider Demographics
NPI:1740588870
Name:LUTZ, KELLIE A (PHARM D)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:A
Last Name:LUTZ
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:L
Other - Last Name:MELERINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARM D
Mailing Address - Street 1:403 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:WAVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39576-2507
Mailing Address - Country:US
Mailing Address - Phone:228-467-9247
Mailing Address - Fax:228-467-4207
Practice Address - Street 1:403 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:WAVELAND
Practice Address - State:MS
Practice Address - Zip Code:39576-2507
Practice Address - Country:US
Practice Address - Phone:228-467-9247
Practice Address - Fax:228-467-4207
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010294183500000X
LAPST.018287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist