Provider Demographics
NPI:1427448968
Name:LUTGEN, TIMOTHY (MS, RPH, PD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:LUTGEN
Suffix:
Gender:M
Credentials:MS, RPH, PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 W LEISURE LN
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:WI
Mailing Address - Zip Code:54547-9330
Mailing Address - Country:US
Mailing Address - Phone:715-367-6690
Mailing Address - Fax:
Practice Address - Street 1:2147 W LEISURE LN
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:WI
Practice Address - Zip Code:54547-9330
Practice Address - Country:US
Practice Address - Phone:715-367-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9342-40183500000X
MN118158183500000X
MI5302035509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist