Provider Demographics
NPI:1811543705
Name:LUTZ, MADELINE ROSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 ROYALWOOD LN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8537
Mailing Address - Country:US
Mailing Address - Phone:407-739-7326
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL STE A110
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-303-4639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist