Provider Demographics
NPI:1518356500
Name:RUSIN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RUSIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 WAKE FOREST RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-3704
Mailing Address - Country:US
Mailing Address - Phone:919-957-4512
Mailing Address - Fax:919-957-4538
Practice Address - Street 1:5111 WAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-3704
Practice Address - Country:US
Practice Address - Phone:919-957-4512
Practice Address - Fax:919-957-4538
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24049183500000X
FLPS22954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist