Provider Demographics
NPI:1285668483
Name:RUSSELLS PHARMACY UPSTATE HOME RESPIRATORY EQUIPMENT INC
Entity Type:Organization
Organization Name:RUSSELLS PHARMACY UPSTATE HOME RESPIRATORY EQUIPMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-654-2485
Mailing Address - Street 1:106 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:NY
Mailing Address - Zip Code:12822-1026
Mailing Address - Country:US
Mailing Address - Phone:518-654-2485
Mailing Address - Fax:518-654-7555
Practice Address - Street 1:106 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:NY
Practice Address - Zip Code:12822-1026
Practice Address - Country:US
Practice Address - Phone:518-654-2485
Practice Address - Fax:518-654-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02570643Medicaid
NY10019380OtherCDPHP
NY01240995Medicaid
NY10019380OtherCDPHP