Provider Demographics
NPI:1083257687
Name:RUTH, JEANETTE CHRISTINE
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:CHRISTINE
Last Name:RUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2311
Mailing Address - Country:US
Mailing Address - Phone:321-254-4170
Mailing Address - Fax:321-254-4126
Practice Address - Street 1:3950 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2311
Practice Address - Country:US
Practice Address - Phone:321-254-4170
Practice Address - Fax:321-254-4126
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2019-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS33274183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty