Provider Demographics
NPI:1477875573
Name:RUSSELL, ROBERT RICHARD II (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RICHARD
Last Name:RUSSELL
Suffix:II
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 1:32 FREDERICKS RD
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-5734
Mailing Address - Country:US
Mailing Address - Phone:518-399-5599
Mailing Address - Fax:
Practice Address - Street 1:3 HEMPHILL PL
Practice Address - Street 2:SUITE 116
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4419
Practice Address - Country:US
Practice Address - Phone:518-899-6063
Practice Address - Fax:518-899-6064
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist