Provider Demographics
NPI:1467704601
Name:SEGRAVES, RUSSELL PATRICK (PHARMD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:PATRICK
Last Name:SEGRAVES
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 1:258 HUNTING HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-5043
Mailing Address - Country:US
Mailing Address - Phone:678-866-3306
Mailing Address - Fax:
Practice Address - Street 1:2175 PARKLAKE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2845
Practice Address - Country:US
Practice Address - Phone:706-363-2464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0199671835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist