Provider Demographics
NPI:1720215742
Name:RUSSELL, JOHN G (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:RUSSELL
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 1:6350 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1039
Mailing Address - Country:US
Mailing Address - Phone:716-706-2320
Mailing Address - Fax:716-684-9192
Practice Address - Street 1:6350 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-1039
Practice Address - Country:US
Practice Address - Phone:716-706-2320
Practice Address - Fax:716-684-9192
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist