Provider Demographics
NPI:1225323199
Name:RUCKMAN, DAVID PAUL
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:PAUL
Last Name:RUCKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MILLERVILLE RD
Mailing Address - Street 2:TARGET PHARMACY STORE NUMBER T-2089
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1408
Mailing Address - Country:US
Mailing Address - Phone:225-275-2109
Mailing Address - Fax:225-275-2109
Practice Address - Street 1:2001 MILLERVILLE RD
Practice Address - Street 2:TARGET PHARMACY STORE NUMBER T-2089
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-1408
Practice Address - Country:US
Practice Address - Phone:225-275-2109
Practice Address - Fax:225-275-2109
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist