Provider Demographics
NPI:1598065203
Name:RUSSO, DOMENIC VINCENT (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:VINCENT
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 S BERNARDO AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1020
Mailing Address - Country:US
Mailing Address - Phone:408-855-0985
Mailing Address - Fax:
Practice Address - Street 1:639 S BERNARDO AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-1020
Practice Address - Country:US
Practice Address - Phone:408-855-0985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist