Provider Demographics
NPI:1225631948
Name:RUSSELL, DONALD RAY (RPH)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:RAY
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 1:2353 BRENTFORD LANE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-0135
Mailing Address - Country:US
Mailing Address - Phone:317-258-7557
Mailing Address - Fax:
Practice Address - Street 1:8191 UPLAND BEND
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113
Practice Address - Country:US
Practice Address - Phone:317-856-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26012545A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist