Provider Demographics
NPI:1548795602
Name:MCBRIDE, RUSSELL III
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MCBRIDE
Suffix:III
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 1:1428 MARION WALDO RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-7422
Mailing Address - Country:US
Mailing Address - Phone:740-386-2321
Mailing Address - Fax:740-389-2795
Practice Address - Street 1:1428 MARION WALDO RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-7422
Practice Address - Country:US
Practice Address - Phone:740-386-2321
Practice Address - Fax:740-389-2795
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03112250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist