Provider Demographics
NPI:1295243871
Name:RUCKER, BRENT LEWIS (PHARMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:LEWIS
Last Name:RUCKER
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 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-497-5355
Mailing Address - Fax:423-308-0281
Practice Address - Street 1:4972 ALPHA LANE
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343
Practice Address - Country:US
Practice Address - Phone:423-497-5360
Practice Address - Fax:423-305-7269
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist