Provider Demographics
NPI:1275526782
Name:RUSSELL, LESLIE W (R PH)
Entity Type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:W
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13441 ASH RD
Mailing Address - Street 2:
Mailing Address - City:RICHVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:62877-1112
Mailing Address - Country:US
Mailing Address - Phone:618-322-4894
Mailing Address - Fax:
Practice Address - Street 1:415 S 42ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6266
Practice Address - Country:US
Practice Address - Phone:618-244-9660
Practice Address - Fax:618-244-9551
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist