Provider Demographics
NPI:1528605292
Name:MILLER, RONALD LYNN
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:LYNN
Last Name:MILLER
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 1:1125 W STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3185
Mailing Address - Country:US
Mailing Address - Phone:269-426-4487
Mailing Address - Fax:260-424-3079
Practice Address - Street 1:1125 W STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-3185
Practice Address - Country:US
Practice Address - Phone:269-426-4487
Practice Address - Fax:260-424-3079
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015215A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist