Provider Demographics
NPI:1326649849
Name:RUCKER, NATHAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:RUCKER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9525
Mailing Address - Country:US
Mailing Address - Phone:662-349-3740
Mailing Address - Fax:
Practice Address - Street 1:465 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9525
Practice Address - Country:US
Practice Address - Phone:662-349-3740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36146183500000X
MSE-11822183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist