Provider Demographics
NPI:1376724021
Name:RUSSO, CHARLES V (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:V
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 JANIS ST
Mailing Address - Street 2:
Mailing Address - City:NEW ROADS
Mailing Address - State:IA
Mailing Address - Zip Code:70760-2920
Mailing Address - Country:US
Mailing Address - Phone:225-638-5151
Mailing Address - Fax:225-638-5148
Practice Address - Street 1:906 JANIS ST
Practice Address - Street 2:
Practice Address - City:NEW ROADS
Practice Address - State:IA
Practice Address - Zip Code:70760-2920
Practice Address - Country:US
Practice Address - Phone:225-638-6088
Practice Address - Fax:225-638-6088
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1234371Medicaid