Provider Demographics
NPI:1871860965
Name:CARRUTHERS, ETHAN A (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:A
Last Name:CARRUTHERS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 E STATE ST
Mailing Address - Street 2:APT 304
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3247
Mailing Address - Country:US
Mailing Address - Phone:414-759-2116
Mailing Address - Fax:
Practice Address - Street 1:999 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2210
Practice Address - Country:US
Practice Address - Phone:920-324-4696
Practice Address - Fax:920-324-4910
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16049-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist