MEDICARE: AUSTIN TYLER LOFTHOUSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS57018	FL

General Provider Information

NPI Number	:	1861911224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUSTIN TYLER LOFTHOUSE

Provider Business Mailing Address
First Line	:	6703 2ND AVENUE CIR W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34209-2218
Country	:	US
Telephone Number	:	941-773-7816
Fax Number	:

Provider Business Practice Location Address
First Line	:	7800 LAKE WILSON RD
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33896-9605
Country	:	US
Telephone Number	:	863-420-4236
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2017
Last Update Date	:	09/16/2017

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