Provider Demographics
NPI:1730671629
Name:RUSSELL'S PHARMACY & SHOPPE LLC
Entity Type:Organization
Organization Name:RUSSELL'S PHARMACY & SHOPPE LLC
Other - Org Name:RUSSELL'S PHARMACY & SHOPPE
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:919-908-1060
Mailing Address - Street 1:2116 ANGIER AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-4260
Mailing Address - Country:US
Mailing Address - Phone:919-908-1060
Mailing Address - Fax:919-908-6362
Practice Address - Street 1:2116 ANGIER AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-4260
Practice Address - Country:US
Practice Address - Phone:919-908-1060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730671629Medicaid