Provider Demographics
NPI:1043533268
Name:RUSSO, DANIEL (RPH, PHARMD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3625
Mailing Address - Country:US
Mailing Address - Phone:718-327-2121
Mailing Address - Fax:718-327-7244
Practice Address - Street 1:271 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3625
Practice Address - Country:US
Practice Address - Phone:718-327-2121
Practice Address - Fax:718-327-7244
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist