Provider Demographics
NPI:1275818148
Name:RUSSELL, DAN L (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:L
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 1:3521 PEGRAM CR.
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-322-8048
Mailing Address - Fax:
Practice Address - Street 1:1710 LOUISVILLE AVE.
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-322-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13984183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist