Healthcare Provider Details

I. General information

NPI: 1083443725
Provider Name (Legal Business Name): COLLIN LIETZ PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9525 E 21ST ST N
WICHITA KS
67206-2946
US

IV. Provider business mailing address

9525 E 21ST ST N
WICHITA KS
67206-2946
US

V. Phone/Fax

Practice location:
  • Phone: 316-631-1401
  • Fax: 316-631-1403
Mailing address:
  • Phone: 316-631-1401
  • Fax: 316-631-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-110979
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: