Provider Demographics
NPI:1477835148
Name:STOLTMANN, RUSSELL KARL (RPH)
Entity Type:Individual
Prefix:MRS
First Name:RUSSELL
Middle Name:KARL
Last Name:STOLTMANN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-5044
Mailing Address - Country:US
Mailing Address - Phone:772-878-6353
Mailing Address - Fax:772-878-4967
Practice Address - Street 1:280 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5044
Practice Address - Country:US
Practice Address - Phone:772-878-6353
Practice Address - Fax:772-878-4967
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 27057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS 27057OtherPHARMACY LISCENSE