Provider Demographics
NPI:1790030245
Name:LUTZ, TERESA (RPH)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:503 31ST ST N
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2580
Mailing Address - Country:US
Mailing Address - Phone:218-790-6749
Mailing Address - Fax:218-359-0773
Practice Address - Street 1:503 31ST ST N
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2580
Practice Address - Country:US
Practice Address - Phone:218-790-6749
Practice Address - Fax:218-359-0773
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14479183500000X
ND4271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist