Provider Demographics
NPI:1922382837
Name:CARR, RUSSEL
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:
Last Name:CARR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-3856
Mailing Address - Country:US
Mailing Address - Phone:248-652-4429
Mailing Address - Fax:
Practice Address - Street 1:2050 S ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-3856
Practice Address - Country:US
Practice Address - Phone:248-652-4429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist