Provider Demographics
NPI:1417009788
Name:RUSSELL, MARTIN ANTHONY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:ANTHONY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4808 DERUSSEY PKWY
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-5328
Mailing Address - Country:US
Mailing Address - Phone:202-256-5952
Mailing Address - Fax:
Practice Address - Street 1:WRAMC BLDG DEPT OF PHARMACY
Practice Address - Street 2:6900 GEORGIA AVE NW
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20307-0001
Practice Address - Country:US
Practice Address - Phone:202-782-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist