Provider Demographics
NPI:1700849718
Name:RUSSO, GIRIACO (RPH)
Entity Type:Individual
Prefix:MR
First Name:GIRIACO
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RANAUDO ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-4704
Mailing Address - Country:US
Mailing Address - Phone:203-768-7355
Mailing Address - Fax:
Practice Address - Street 1:153 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-4256
Practice Address - Country:US
Practice Address - Phone:203-729-2297
Practice Address - Fax:203-729-1134
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist