Provider Demographics
NPI:1902920838
Name:LUEDTKE, JON ROBERT (RPH)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:ROBERT
Last Name:LUEDTKE
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 1:1501 VISCAYA PKWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-6207
Mailing Address - Country:US
Mailing Address - Phone:239-772-8866
Mailing Address - Fax:239-772-7117
Practice Address - Street 1:1501 VISCAYA PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-6207
Practice Address - Country:US
Practice Address - Phone:239-772-8866
Practice Address - Fax:239-772-7117
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25896183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109745800Medicaid
FL109745800Medicaid