Provider Demographics
NPI:1699405753
Name:RUSSELL, CAROL ANN
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
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 1:15801 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-6904
Mailing Address - Country:US
Mailing Address - Phone:253-531-7427
Mailing Address - Fax:253-535-9279
Practice Address - Street 1:15801 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-6904
Practice Address - Country:US
Practice Address - Phone:253-561-7427
Practice Address - Fax:253-535-9279
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00021327183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician