Provider Demographics
NPI:1376737973
Name:RUSSOS HEALTH MART INC
Entity Type:Organization
Organization Name:RUSSOS HEALTH MART INC
Other - Org Name:RUSSOS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALVADORE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:985-384-1234
Mailing Address - Street 1:PO BOX 2703
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70381-2703
Mailing Address - Country:US
Mailing Address - Phone:985-384-1234
Mailing Address - Fax:985-384-1233
Practice Address - Street 1:1124 7TH ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1951
Practice Address - Country:US
Practice Address - Phone:985-384-1234
Practice Address - Fax:985-384-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
LAPHY000755IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1908194OtherNCPDP PROVIDER IDENTIFICATION NUMBER
LA1228796Medicaid