Provider Demographics
NPI:1407905953
Name:RUSSELL, MARCIA MAXINE
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:MAXINE
Last Name:RUSSELL
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 1:5811 220TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1921
Mailing Address - Country:US
Mailing Address - Phone:718-631-0207
Mailing Address - Fax:212-939-1759
Practice Address - Street 1:5811 220TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-1921
Practice Address - Country:US
Practice Address - Phone:718-631-0207
Practice Address - Fax:212-939-1759
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist