Provider Demographics
NPI:1124624200
Name:RUMBLE, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:RUMBLE
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 1:10166 EAGLE CREST LN
Mailing Address - Street 2:
Mailing Address - City:ELBERFELD
Mailing Address - State:IN
Mailing Address - Zip Code:47613
Mailing Address - Country:US
Mailing Address - Phone:812-779-8898
Mailing Address - Fax:
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-8525
Practice Address - Country:US
Practice Address - Phone:812-354-8939
Practice Address - Fax:812-354-2623
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022028A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist