Healthcare Provider Details

I. General information

NPI: 1346799178
Provider Name (Legal Business Name): BETHANY RUGGLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N MARKET ST
SPARTA IL
62286-2302
US

IV. Provider business mailing address

1410 N MARKET ST
SPARTA IL
62286-2302
US

V. Phone/Fax

Practice location:
  • Phone: 618-443-2436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051295924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: