Provider Demographics
NPI:1497040042
Name:RUSSAKOW, MITCHELL BERNARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:BERNARD
Last Name:RUSSAKOW
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 1:72549 HIGHWAY 111
Mailing Address - Street 2:TARGET 0940
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3306
Mailing Address - Country:US
Mailing Address - Phone:760-776-1113
Mailing Address - Fax:760-776-1113
Practice Address - Street 1:72549 HIGHWAY 111
Practice Address - Street 2:TARGET 0940
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3306
Practice Address - Country:US
Practice Address - Phone:760-776-1113
Practice Address - Fax:760-776-1113
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-11
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist