NPIMap

Organization Active NPI

Mary Rutan Indian Lake Pharmacy

  • Community/Retail Pharmacy
  • Russells Point, OH
National Provider Identifier
1790665172
Registry record updated Dec 19, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
MARY RUTAN INDIAN LAKE PHARMACY
Practice address
120 W Main St
Russells Point, OH 43348-7500
Phone
(937) 292-5024
Fax
(937) 292-3576
NPI assigned
Sep 5, 2025
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 19, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Christina Myers
Title
Coo
Phone
(937) 599-7034

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X Primary

Addresses

Primary practice location

120 W Main St
Russells Point, OH 43348-7500

Mailing address

205 E Palmer Rd
Bellefontaine, OH 43311-2281
Phone (937) 292-5024

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
36D2163056Mary Rutan Indian Lake Health Center120 W Main St, Russells Point, OH 43348Certificate of waiverMar 5, 2027

National Provider Directory

National Provider Directory
Tax ID family
Ralph a Cardamone MD PC12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1757030400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1766102400000",
    "number": "1790665172",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 E PALMER RD",
            "city": "BELLEFONTAINE",
            "state": "OH",
            "postal_code": "433112281",
            "telephone_number": "937-292-5024",
            "fax_number": "937-292-3576"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 W MAIN ST",
            "city": "RUSSELLS POINT",
            "state": "OH",
            "postal_code": "433487500",
            "telephone_number": "937-292-5024",
            "fax_number": "937-292-3576"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARY RUTAN INDIAN LAKE PHARMACY",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-09-05",
        "last_updated": "2025-12-19",
        "certification_date": "2025-12-19",
        "status": "A",
        "authorized_official_last_name": "MYERS",
        "authorized_official_first_name": "CHRISTINA",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "937-599-7034"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Russells Point, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.