Provider Demographics
NPI:1033255005
Name:RUTHERFORD, EDDIE D (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:D
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13519 HIGHWAY 19 S
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-5607
Mailing Address - Country:US
Mailing Address - Phone:662-289-1551
Mailing Address - Fax:
Practice Address - Street 1:13519 HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-5607
Practice Address - Country:US
Practice Address - Phone:662-289-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-8651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03623872Medicaid