Provider Demographics
NPI:1700402864
Name:RUSSO, SAMANTHA ANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANNE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JACOB LN
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-1776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 JACOB LN
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-1776
Practice Address - Country:US
Practice Address - Phone:763-421-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist