Provider Demographics
NPI:1720098122
Name:RUSHVILLE PHARMACY, INC.
Entity Type:Organization
Organization Name:RUSHVILLE PHARMACY, INC.
Other - Org Name:RUSHVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIPLAND
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:BURKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-932-3328
Mailing Address - Street 1:302 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-1636
Mailing Address - Country:US
Mailing Address - Phone:765-932-3328
Mailing Address - Fax:765-932-3824
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-1636
Practice Address - Country:US
Practice Address - Phone:765-932-3328
Practice Address - Fax:765-932-3824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IN60001488A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100300760Medicaid
IN1500481OtherNCPDP