Provider Demographics
NPI:1477195949
Name:RUSSELL, MACY B (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MACY
Middle Name:B
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13630 BANDYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-6514
Mailing Address - Country:US
Mailing Address - Phone:618-694-5318
Mailing Address - Fax:
Practice Address - Street 1:1606 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-4169
Practice Address - Country:US
Practice Address - Phone:618-942-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist