Provider Demographics
NPI:1326362815
Name:RUSSO, KELLY T
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:T
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-1224
Mailing Address - Country:US
Mailing Address - Phone:315-673-2410
Mailing Address - Fax:315-673-9668
Practice Address - Street 1:11 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108-1224
Practice Address - Country:US
Practice Address - Phone:315-673-2410
Practice Address - Fax:315-673-9668
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist