Provider Demographics
NPI:1780674408
Name:RUSSELL, BONNIE PORTER (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:PORTER
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HOLLY HILL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-8917
Mailing Address - Country:US
Mailing Address - Phone:270-737-4245
Mailing Address - Fax:270-769-2887
Practice Address - Street 1:910 N DIXIE AVE
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
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY006992OtherPHARMACIST LICENSCE NUMBE