Provider Demographics
NPI:1639515380
Name:RUTLEDGE PHARMACY AND MEDICAL SUPPLIES LLC
Entity Type:Organization
Organization Name:RUTLEDGE PHARMACY AND MEDICAL SUPPLIES LLC
Other - Org Name:RUTLEDGE PHARMACY AND MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-265-1740
Mailing Address - Street 1:2470 LEONE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6169
Mailing Address - Country:US
Mailing Address - Phone:770-728-9624
Mailing Address - Fax:770-728-9729
Practice Address - Street 1:2470 LEONE AVE STE E
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6147
Practice Address - Country:US
Practice Address - Phone:770-728-9624
Practice Address - Fax:770-728-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
GAPHRE0099243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140429OtherPK