Provider Demographics
NPI:1962749606
Name:RUTKOWSKI, BRAD DAVID (PHARMD)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:DAVID
Last Name:RUTKOWSKI
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 1:27615 US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748
Mailing Address - Country:US
Mailing Address - Phone:352-787-2122
Mailing Address - Fax:352-787-3306
Practice Address - Street 1:27615 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-9396
Practice Address - Country:US
Practice Address - Phone:352-787-2122
Practice Address - Fax:352-787-3306
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist