Provider Demographics
NPI:1710977442
Name:LARRY J & BONNIE P RUSSELL
Entity Type:Organization
Organization Name:LARRY J & BONNIE P RUSSELL
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-769-3717
Mailing Address - Street 1:910 N DIXIE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2519
Mailing Address - Country:US
Mailing Address - Phone:270-769-3717
Mailing Address - Fax:270-769-2887
Practice Address - Street 1:910 N DIXIE AVE STE 105
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2519
Practice Address - Country:US
Practice Address - Phone:270-769-3717
Practice Address - Fax:270-769-2887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP01397333600000X
KY3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1813131OtherNCPDP #
KY5401676100Medicaid
KYAT9527877OtherDEA #
KY5401676100Medicaid
KY1813131OtherNCPDP #