Provider Demographics
NPI:1669470084
Name:RUSSELL'S PHARMACY, INC
Entity Type:Organization
Organization Name:RUSSELL'S PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:901-327-7323
Mailing Address - Street 1:2455 CHELSEA AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38108-2404
Mailing Address - Country:US
Mailing Address - Phone:901-327-7323
Mailing Address - Fax:901-323-0228
Practice Address - Street 1:2455 CHELSEA AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38108-2404
Practice Address - Country:US
Practice Address - Phone:901-327-7323
Practice Address - Fax:901-323-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN840183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3546583Medicaid
TN840OtherSTATE PHARMACY NUMBER
TN840OtherSTATE PHARMACY NUMBER
TN3546583Medicaid