Provider Demographics
NPI:1821370263
Name:RUSSELL, AMY M (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
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 1:9101 SUN ISLE DR NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2617
Mailing Address - Country:US
Mailing Address - Phone:404-372-7025
Mailing Address - Fax:
Practice Address - Street 1:9101 SUN ISLE DR NE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2617
Practice Address - Country:US
Practice Address - Phone:404-372-7025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32615183500000X
FLPU59061835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric