Provider Demographics
NPI:1861911224
Name:LOFTHOUSE, AUSTIN TYLER
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:TYLER
Last Name:LOFTHOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6703 2ND AVENUE CIR W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-2218
Mailing Address - Country:US
Mailing Address - Phone:941-773-7816
Mailing Address - Fax:
Practice Address - Street 1:7800 LAKE WILSON RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-9605
Practice Address - Country:US
Practice Address - Phone:863-420-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2017-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist