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General NPI Number Information
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NPI Number | 1790665172
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Entity Type | Organization
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Legal Business Name | MARY RUTAN INDIAN LAKE PHARMACY
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Dates
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Enumeration Date | 09/05/2025
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Last Update Date | 12/19/2025
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Provider Practice Location Address
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Address Line | 120 W MAIN ST
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City | RUSSELLS POINT
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State | OH
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Zip | 43348-7500
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Country | US
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Telephone | 937-292-5024
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Fax | 937-292-3576
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Provider Business Mailing Address
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Address Line | 205 E PALMER RD
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City | BELLEFONTAINE
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State | OH
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Zip | 43311-2281
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Country | US
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Telephone | 937-292-5024
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Fax | 937-292-3576
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Authorized Official
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Title or Position | COO
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Name | CHRISTINA MYERS
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Credential |
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Telephone | 937-599-7034
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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