Provider Demographics
NPI:1124346911
Name:LUTZ, RANDY W (RPH)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:W
Last Name:LUTZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6414 STATE PARK RD
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-1634
Mailing Address - Country:US
Mailing Address - Phone:864-834-7936
Mailing Address - Fax:864-834-5672
Practice Address - Street 1:6414 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1634
Practice Address - Country:US
Practice Address - Phone:864-834-7936
Practice Address - Fax:864-834-5672
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist