Provider Demographics
NPI:1912590878
Name:RUTLEDGE, TRACI LYNN (RPH)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-1824
Mailing Address - Country:US
Mailing Address - Phone:419-586-8875
Mailing Address - Fax:
Practice Address - Street 1:510 E MARKET ST
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1824
Practice Address - Country:US
Practice Address - Phone:419-586-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03319964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03319964OtherPHARMACIST LICENSE