Provider Demographics
NPI:1326341157
Name:AGEE, RUSSELL LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LYNN
Last Name:AGEE
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 1:3344 KENWICK TRL
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4907
Mailing Address - Country:US
Mailing Address - Phone:540-761-1151
Mailing Address - Fax:540-342-5910
Practice Address - Street 1:614 BRANDON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3212
Practice Address - Country:US
Practice Address - Phone:540-342-9897
Practice Address - Fax:540-342-5910
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202010009OtherVIRGINIA PHARMACIST LICENSE NUMBER