Provider Demographics
NPI:1578862330
Name:RUSSO, CHAD (PHAMD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PHAMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 W PINEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-3235
Practice Address - Country:US
Practice Address - Phone:559-441-0998
Practice Address - Fax:559-441-1088
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist