Provider Demographics
NPI:1821691361
Name:RUSSELL, GARY STEPHEN (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:STEPHEN
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 1:1128 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1265
Mailing Address - Country:US
Mailing Address - Phone:270-825-2775
Mailing Address - Fax:270-825-0413
Practice Address - Street 1:1128 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1265
Practice Address - Country:US
Practice Address - Phone:270-825-2775
Practice Address - Fax:270-825-0413
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist