Provider Demographics
NPI:1376865055
Name:RUSSAK, EDWARD MORRY (RPH)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MORRY
Last Name:RUSSAK
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 1:253 LAKEFRONT BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4316
Mailing Address - Country:US
Mailing Address - Phone:716-854-1790
Mailing Address - Fax:
Practice Address - Street 1:253 LAKEFRONT BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4316
Practice Address - Country:US
Practice Address - Phone:716-854-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist