Basic Information
Provider Information
NPI: 1962956755
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LUTTROPP
FirstName: MARY
MiddleName: VALENTINE
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 20170 PUTNAM LN
Address2:  
City: BEND
State: OR
PostalCode: 977038935
CountryCode: US
TelephoneNumber: 5036806774
FaxNumber:  
Practice Location
Address1: 2500 NE NEFF RD
Address2:  
City: BEND
State: OR
PostalCode: 977016015
CountryCode: US
TelephoneNumber: 5413824321
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/09/2016
LastUpdateDate: 08/09/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000XRPH-0013219ORY Pharmacy Service ProvidersPharmacist 

No ID Information.


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