Provider Demographics
NPI:1841572120
Name:RUSSELL, MARK (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S 490 E
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-1220
Mailing Address - Country:US
Mailing Address - Phone:435-563-2777
Mailing Address - Fax:
Practice Address - Street 1:999 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3230
Practice Address - Country:US
Practice Address - Phone:435-227-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7284773-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist