Provider Demographics
NPI:1790665172
Name:MARY RUTAN INDIAN LAKE PHARMACY
Entity type:Organization
Organization Name:MARY RUTAN INDIAN LAKE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-599-7034
Mailing Address - Street 1:205 E PALMER RD
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2281
Mailing Address - Country:US
Mailing Address - Phone:937-292-5024
Mailing Address - Fax:937-292-5044
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLS POINT
Practice Address - State:OH
Practice Address - Zip Code:43348-7500
Practice Address - Country:US
Practice Address - Phone:937-292-5024
Practice Address - Fax:937-292-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy