Provider Demographics
NPI:1043806508
Name:RUSSO, ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-3271
Mailing Address - Country:US
Mailing Address - Phone:781-231-5775
Mailing Address - Fax:
Practice Address - Street 1:164 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-3271
Practice Address - Country:US
Practice Address - Phone:781-231-5775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPH24194OtherPHARMACY LICENSE