Provider Demographics
NPI:1194387308
Name:RUSSELL, STEPHANIE (RPH)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 DELL RANGE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4853
Mailing Address - Country:US
Mailing Address - Phone:307-635-5854
Mailing Address - Fax:307-635-5865
Practice Address - Street 1:1501 DELL RANGE BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4853
Practice Address - Country:US
Practice Address - Phone:307-635-5854
Practice Address - Fax:307-635-5865
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4149183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist