Provider Demographics
NPI:1811000441
Name:RUSSELL, SUSAN ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ANN
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 1:804 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-3025
Mailing Address - Country:US
Mailing Address - Phone:505-552-5394
Mailing Address - Fax:505-552-5464
Practice Address - Street 1:I-40, EXIT 102
Practice Address - Street 2:
Practice Address - City:SAN FIDEL
Practice Address - State:NM
Practice Address - Zip Code:87049
Practice Address - Country:US
Practice Address - Phone:505-552-5394
Practice Address - Fax:505-552-5464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM00005516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist