Provider Demographics
NPI:1033654967
Name:RUSSELL, MARK (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:RUSSELL
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 1:5118 JADE PASTURE LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-8229
Mailing Address - Country:US
Mailing Address - Phone:865-776-7131
Mailing Address - Fax:
Practice Address - Street 1:2920 KNOXVILLE CENTER DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-2013
Practice Address - Country:US
Practice Address - Phone:865-637-0643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist