Provider Demographics
NPI:1790070100
Name:LAITE, LUTHER V IV (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LUTHER
Middle Name:V
Last Name:LAITE
Suffix:IV
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 REEF PL
Mailing Address - Street 2:
Mailing Address - City:MALABAR
Mailing Address - State:FL
Mailing Address - Zip Code:32950-4631
Mailing Address - Country:US
Mailing Address - Phone:321-749-2989
Mailing Address - Fax:
Practice Address - Street 1:3500 REEF PL
Practice Address - Street 2:
Practice Address - City:MALABAR
Practice Address - State:FL
Practice Address - Zip Code:32950-4631
Practice Address - Country:US
Practice Address - Phone:321-749-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist