Provider Demographics
NPI:1356655906
Name:MINOR, RUSSELL ALLEN
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALLEN
Last Name:MINOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 SE MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-3814
Mailing Address - Country:US
Mailing Address - Phone:210-333-1031
Mailing Address - Fax:210-359-1498
Practice Address - Street 1:3323 SE MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3814
Practice Address - Country:US
Practice Address - Phone:210-333-1031
Practice Address - Fax:210-359-1498
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist