Provider Demographics
NPI:1841802451
Name:RUSSELL, ANTHONY (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5093 HARDY ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1336
Mailing Address - Country:US
Mailing Address - Phone:601-579-6698
Mailing Address - Fax:
Practice Address - Street 1:5093 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1336
Practice Address - Country:US
Practice Address - Phone:601-579-6698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-15276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist