Provider Demographics
NPI:1780022780
Name:RUSCH RX INC
Entity Type:Organization
Organization Name:RUSCH RX INC
Other - Org Name:RUSCH'S SOUTHSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-316-0079
Mailing Address - Street 1:1107 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4223
Mailing Address - Country:US
Mailing Address - Phone:812-316-0079
Mailing Address - Fax:812-316-0510
Practice Address - Street 1:1107 S 15TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-4223
Practice Address - Country:US
Practice Address - Phone:812-316-0079
Practice Address - Fax:812-316-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60006339A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201165910 AMedicaid
IN201165910AMedicaid
2140731OtherPK