Provider Demographics
NPI:1629466776
Name:RUSSO, RICHARD (BS, PHARM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:BS, PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-0099
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5491 BAYVIEW RD
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260-9763
Practice Address - Country:US
Practice Address - Phone:206-992-1809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00041665183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist