Provider Demographics
NPI:1578164141
Name:MILLER, CHAD RUSSELL
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:RUSSELL
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 1:3216 N 50 W
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-7842
Mailing Address - Country:US
Mailing Address - Phone:260-609-8125
Mailing Address - Fax:
Practice Address - Street 1:402 W PLAZA DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1051
Practice Address - Country:US
Practice Address - Phone:260-244-4400
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
IN26020465A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist