Provider Demographics
NPI:1093092553
Name:RUSSELL, THOMAS WOODROW (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WOODROW
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4299 WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1709
Mailing Address - Country:US
Mailing Address - Phone:859-291-4722
Mailing Address - Fax:859-291-5429
Practice Address - Street 1:4299 WINSTON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-1709
Practice Address - Country:US
Practice Address - Phone:859-291-4722
Practice Address - Fax:859-291-5429
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist