MEDICARE: MARY RUTAN INDIAN LAKE PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1790665172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY RUTAN INDIAN LAKE PHARMACY

Provider Business Mailing Address
First Line	:	205 E PALMER RD
Second Line	:
City	:	BELLEFONTAINE
State	:	OH
Zip	:	43311-2281
Country	:	US
Telephone Number	:	937-292-5024
Fax Number	:	937-292-5044

Provider Business Practice Location Address
First Line	:	120 W MAIN ST
Second Line	:
City	:	RUSSELLS POINT
State	:	OH
Zip	:	43348-7500
Country	:	US
Telephone Number	:	937-292-5024
Fax Number	:	937-292-5044

Authorized Official
Title or Position	:	COO
Name	:	CHRISTINA MYERS
Credential	:
Telephone Number	:	937-599-7034

Provider Enumeration Date	:	09/05/2025
Last Update Date	:	09/05/2025

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