Healthcare Provider Details

I. General information

NPI: 1033609227
Provider Name (Legal Business Name): MS LUTZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16142 FLIGHT PATH DR
BROOKSVILLE FL
34604-6845
US

IV. Provider business mailing address

16142 FLIGHT PATH DR
BROOKSVILLE FL
34604-6845
US

V. Phone/Fax

Practice location:
  • Phone: 561-543-4440
  • Fax: 888-891-1847
Mailing address:
  • Phone: 561-543-4440
  • Fax: 888-891-1847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH31405
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RYAN GOODKIN
Title or Position: OWNER
Credential:
Phone: 561-208-1097