Provider Demographics
NPI:1568236420
Name:RUSSELL, HAILEY DYLANA
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:DYLANA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CONNECTICUT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-2541
Mailing Address - Country:US
Mailing Address - Phone:716-923-4603
Mailing Address - Fax:
Practice Address - Street 1:301 CONNECTICUT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-2541
Practice Address - Country:US
Practice Address - Phone:716-923-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist