Provider Demographics
NPI:1417226101
Name:RUSSELL, JERRY F JR
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:F
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 UPPER MANATEE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-9702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 UPPER MANATEE RIVER RD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212-9702
Practice Address - Country:US
Practice Address - Phone:941-462-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-24
Last Update Date:2011-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS021868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist