Provider Demographics
NPI:1609477793
Name:RUSK, DONALD LOWELL
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:LOWELL
Last Name:RUSK
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 1:2350 W BUNKUM RD
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-8902
Mailing Address - Country:US
Mailing Address - Phone:219-863-8114
Mailing Address - Fax:219-866-0456
Practice Address - Street 1:WALMART
Practice Address - Street 2:905 S COLLEGE AVE
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978
Practice Address - Country:US
Practice Address - Phone:219-866-0466
Practice Address - Fax:219-866-0456
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014128A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist