Healthcare Provider Details

I. General information

NPI: 1265054134
Provider Name (Legal Business Name): RANDOLPH W LUTZ RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11300 CORPORATE AVE
LENEXA KS
66219-1374
US

IV. Provider business mailing address

11300 CORPORATE AVE
LENEXA KS
66219-1374
US

V. Phone/Fax

Practice location:
  • Phone: 913-449-4992
  • Fax: 913-574-0252
Mailing address:
  • Phone: 913-588-2370
  • Fax: 913-574-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-10405
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: