Provider Demographics
NPI:1114119682
Name:RUSSELL, BOBBY JAMES (DPH)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:JAMES
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5883
Mailing Address - Country:US
Mailing Address - Phone:731-885-9441
Mailing Address - Fax:731-885-7861
Practice Address - Street 1:705 E REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5883
Practice Address - Country:US
Practice Address - Phone:731-885-9441
Practice Address - Fax:731-885-7861
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist