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General NPI Number Information
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NPI Number | 1861911224
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Entity Type | Individual
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Provider Name | AUSTIN TYLER LOFTHOUSE
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Gender | Male
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Dates
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Enumeration Date | 09/16/2017
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Last Update Date | 09/16/2017
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Provider Practice Location Address
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Address Line | 7800 LAKE WILSON RD
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City | DAVENPORT
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State | FL
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Zip | 33896-9605
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Country | US
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Telephone | 863-420-4236
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Fax |
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Provider Business Mailing Address
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Address Line | 6703 2ND AVENUE CIR W
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City | BRADENTON
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State | FL
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Zip | 34209-2218
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Country | US
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Telephone | 941-773-7816
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PS57018
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License Number State | FL
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