Provider Demographics
NPI:1083210405
Name:TAMASCO, RUSSELL LESLIE
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LESLIE
Last Name:TAMASCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CVS #1814
Mailing Address - Street 2:3932 COTTAGE HILL RD
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695
Mailing Address - Country:US
Mailing Address - Phone:251-661-1190
Mailing Address - Fax:
Practice Address - Street 1:CVS #1814
Practice Address - Street 2:3932 COTTAGE HILL RD
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695
Practice Address - Country:US
Practice Address - Phone:251-661-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty